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MANUALS 

FOK 

Students   of  Medicine. 


ELEMENTS 


OF 


Surgical  Pathology. 


BY 

AUGUSTUS    J.     PEPPEE, 

M.S.,  M.B.  LOND.,  F.E.C.S.  Eng., 

FELLOW  OF  UNIVERSITY    COLLEGE,   LONDON  ;     SURGEON    TO    ST,   MAET'S 

HOSPITAL;     AND  TEACHER  OF  PRACTICAL  AND  OPERATIVE 

SURGERY  AT  THE   MEDICAL  SCHOOL. 


ILLUSTRATED  WITK  81  ENGBAVINQS. 


HENRY    C.    LEA'S    SON    &    CO,: 
PHILADELPHIA,     PA, 


^0 

GEOKGE   VINER  ELLIS,  Esq.,  F.R.C.S., 

Emeritus  Professor  of  Anatomy  in  University   College,  London, 

THIS    WORK    IS    DEDICATED, 

IN    GRATEFUL    ACKNOWLEDGMENT    OF    MANY  ACTS    OF    KINDNESS  ; 

BY    HIS    FORMER   FI'PIL, 

THE    AUTHOR. 


PEEFACE 


My  aim  has  been  to  supply  what  has  long  been 
felt  as  a  desideratum,  a  small  work  on  Surgical 
Pathology  suited  to  the  requirements  of  Students 
preparing  for  the  final  examinations. 

The  following  pages  embody  some  of  the  con- 
clusions arrived  at  after  many  years  of  study  and 
teaching.  An  attempt  has  been  made  to  render  in 
a  practical  form  the  knowledge  conveyed,  and  to 
give  an  explanation  of  the  causes  and  methods  of 
pathological  processes. 

My  thanks  are  due  to  Mr.  Charles  Berjeau, 
who  has  drawn  the  figures  on  wood,  for  the  most 
part  from  coarse  preparations  and  sketches  made 
by  myself. 

Of  the  eighty-one  figures  with  which  the  book 
is  illustrated,  sixty-six  are  original,  the  others  have 
been    copied    from    standard    works     and     formally 


viii  Surgical  Pathology. 

acknowledged.      The  tables  of  "Urinary  Deposits  and 

Calculi "    have    been    taken    from    the    "  Index    of 

Surgery,"  by  my  friend  Mr.   C.   B,   Keetley. 

In  conclusion,  I  have  to  express  my  indebtedness 

to  A.   B.    Shepherd,   Esq.,  M.D.,    late    Dean    of    St. 

Mary's  Medical  School,  for  permission  to   make  use 

of  the  material   furnished   by   the    Museum    of   that 

Institution. 

Augustus  J.  Pepper. 

Octoler,  1883. 


CONTENTS. 


CHAPTER  PAGE 

I. -Inflammation  and  Abscess  ......     1 

II.— Pain 13 

III.— Ulceration 16 

IV.— Gangrene 34 

v.— Fever 41 

VI.— Simple  Surgical  or  Traumatic  Fever    .       .       .    47 

VII.— Septicemia  and  Pyemia 50 

VIII.— Erysipelas 69 

IX.— Furuncle,  Carbuncle,  and  Malignant  Pustule    76 

X.— Hypertrophy 81 

XI.— Atrophy 85 

xn.— Fatty  Infiltration— Fatty  Degeneration  .  .  92 
Xin.— Mucoid  and  Colloid  Degeneration  .  .  .  .100 
XIV.— Pigmentation— Pigmentary  Degeneration   .       .  106 

XV.— Calcareous  Degeneration 112 

XVI.— Albuminoid  Infiltration  :  Synonyms— Amyloid, 

Lardaceous,  Waxy 117 

XVn.— Trophic  Le  jions 121 

XVIII.- Syphilis 128 

XIX.— Rickets 145 

XX.— Tubercle  and  Scrofula 153 

XXI.— Lupus .162 

XXII.— Tetanus 164 

XXIII.— Union  of  Wounds 167 

XXIV.— Fractures  of  Bone  and  Pseudarthrosis      .       .  178 
XXV.— Injuries  and  Diseases  of  the  Scalp      .       .       .193 


X  Surgical  Pathology. 

CHAPTEE  PAGE 

XXVI.— Hernia  Cerebri— Hemorrhage  between  the 

Skull  and  Dura  Mater 196 

XXVII.— Intracranial  Suppuration 198 

XXVIII.— Suppuration  in  the  Mastoid  Cells  .       .       .202 

XXIX.— Pulsation  of  the  Eye-ball 203 

XXX.— Inflammation  op  Bone 205 

XXXI.— Rarefying  Ostitis— Caries 207 

XXXII.— Osteoplastic  or  Formative  Ostitis  and  Peri- 
ostitis   219 

XXXHI. —Acute  Suppurative  Periostitis,  Ostitis,  and 

Osteomyelitis 225 

XXXIV.— Osseous  Lesions  in  Congenital  Syphilis       .  228 

XXXV.— Necrosis 232 

XXXVL— Bone  Abscess 244 

XXXVH.— MoLLiTiES  OssiUM— Osteomalacia       .       .       .245 

XXXVin.- Diseases  of  the  Joints 249 

XXXIX.— Strumous  Arthritis 251 

XL.— Chronic  Rheumatic  Arthritis    .       .       .       .256 
XLL— Acute  Serous  Synovitis— Hydrops  Acutus  .  261 
XLH.- Chronic  Serous  Synovitis      .       .       .       .       .262 
XLIIL— Phlegmonous  or  Suppurative  Arthritis       .  263 
XLIV.— Gonorrhceal  Arthritis,  Gonorrhceal  Rheu- 
matism   265 

XL  v.— Hemorrhage  into  Joints 266 

XL VI.— Loose  or  Movable  Bodies  in  Joints  .       ,       .266 

XL VII.— On  Deformities 268 

XL VIII.— Curvature  of  the  Spine 272 

XLIX.— Deformities  op  the  Foot,  Knee,  and  Hip     .  274 

L.— Spina  Bifida         '    .       .       .278 

LI.— Cerebral  Meningocele  and  Meningo-Ence- 

phalocele 282 

LIL— Cleft  Palate  and  Hare-Lip 282 

LIIL— Extroversion     of     the     Bladder— Ectopia 

Vesica- Hypospadias 284 


Contents.  xi 

CHAPTER  PAGE 

LIV.— Fatty     Degeneration     of    Arteries,     and 

Arteritis 285 

LV.— Aneurism 290 

L VI.— Ligature  of  Arteries     .       .       .       .       .       .298 

LVII.— Yarix 300 

LVni.— Embolism 304 

LIX.— Thrombosis  and  Phlebitis     .       .       .       .       .310 

LX.— Acute  Orchitis  and  Epididymitis      .       .       .  319 

LXI.— Chronic  Enlargements  of  the  Testicle        .  321 

LXn.— Atrophy  of  the  Testicle 337 

LXIII.— Hydrocele 337 

LXIV.— Gonorrhoea  and  its  Consequences    .       .       .341 

LXY.— Stricture  of  the  Urethra 346 

LXVI.— Urinary  Abscess— Extravasation  of  Urine 

—Urinary  Fistula        .       ...       .       .350 

LX VII.— Hypertrophy  of  the  Bladder     .       .       .       .354-^ 

LX VIII.— Cystitis  :  Ulceration  of  the  Bladder     .       .  356 

LXIX.— Tumours  of  the  Bladder 360 

LXX— Hematuria .364 

LXXL— Diseases  of  the  Prostate  Gland       .       .       .366 

LXXIL— Surgical  Kidney 370 

LXXIIL— Urinary  Deposits  and  Calculi   .       .       .       .375 
LXXIV.— Ulcers  of  the  Anus  and  Rectum      .       .       .379 

LXXV.— Stricture  of  the  Rectum 382 

LXXVL— Tumours  of  the  Rectum 385 

LXXVII.— Prolapse,  Hemorrhoids,  and  Fistula     .       .  389 

LXXVIII.— Peritonitis 392 

LXXIX.— Strangulated  Hernia      ......  399 

LXXX.— Intussusception  of  the  Bowel    .       .       .       .403 

LXXXL— Tumours .       .       .405 

LXXXH.- The  Fibromata    . 408 

LXXXIII.— The  Lipomata 412 

LXXXIV.— The  Enchondromata 415 

LXXXV.— The  Osteomata 419 


xii  Surgical  Pathology. 

CHAPTER  PAC4E 

LXXXYL— The  Myxomata        .        .       .       .       .       .       .427 

LXXXVII— The  Neuromata 430 

LXXXVIII.— The  Angiomata .434 

LXXXIX.— The  Sarcomata 437 

XC— The  Lymphadenomata 449 

XCI.— The  Papillomata 454 

XCII.— Adenoid  Tumours 458 

XCIII.-Cysts 464 

XCIV.-The  Carcinomata 474 

Index      .      •       .       * 495 


Surgical   Pathology. 


CHAPTER  I. 

INFLAMMATION   AND    ABSCESS. 

So  long  as  tissue  elements  retain  their  vitality 
they  possess  the  property  termed  irritability;  that  is, 
they  are  capable  of  undergoing  nutritive  and  formative 
changes  on  the  application  of  a  physical  or  chemical 
stimulus.  This  varies  in  degree  in  the  different 
tissues,  but  is  much  more  marked  in  those  where 
there  is  a  perpetual  physiological  succession  of  new 
cells  which  take  the  place  of  those  whose  term  of  life 
and  function  has  expired,  as  in  the  epidermis  and 
mucous  epithelium. 

This  increase  of  activity,  whether  showing  itself 
by  enlargement,  and  multiplication  by  division,  or 
endogenous  formation  of  cells,  is  always  a  sign  of 
lowered  vitality ;  for  the  more  rapid  the  rate  of 
nutrition  and  reproduction,  the  less  the  stability,  and 
so  inflammation  must  of  itself  always  be  a  destructive 
process. 

Redness,  pain,  heat,  and  swelling,  the  four  stereo- 
typed factors  of  inflammation,  may  severally  or  in 
combination  be  met  with  in  other  conditions.  Thus, 
redness,  pain,  and  heat  may  be  observed  in  joints,  the 
seat  of  nervous  mimicry  of  disease  (Paget),  swelling 
from  exudation,  as  in  transient  erythema,  and  pain  so 
momentary  as  not  to  admit  of  inflammation  as  a  cause. 

B 


2  Surgical  Pathology.  [Chap.  i. 

In  inflammation  itself  these  signs  are  associated  in 
difierent  degrees ;  thus,  a  joint  may  be  filled  with 
pus  in  purulent  infection,  with  but  little  redness 
of  the  synovial  membrane,  or  it  may  be  intensely 
congested  in  rheumatism  with  only  a  slight  amount 
of  exudation. 

The  redness  is  mainly  due  to  dilatation  of  the 
vessels.  In  very  acute  cases  the  exudation  of  red 
corpuscles  shares  in  its  production,  and  in  some 
diseases  there  is  considerable  discharge  of  the  haemo- 
globin from  the  corpuscles,  which,  passing  out  in  a 
state  of  solution,  stains  the  bodies  with  which  it 
comes  in  contact ;  e.g.^  the  brick-dust  colour  of  the 
lymph  in  syphilitic  iritis;  and  lastly,  in  long-standing 
hypersemia  the  blood  pigment  is  taken  up  and  fixed 
by  the  cells. 

The  pain  is  caused  chiefly  by  the  tension  on  the 
filaments  of  the  nerves  from  the  pressure  of  the 
exudation,  but  partly  by  a  chemical  irritation  of  the 
inflammatory  products  acting  upon  the  ends  of  the 
nerves;  for  it  is  not  always  proportionate  to  the  extent 
of  the  stretching. 

The  local  heat  depends  upon  the  increased  amount 
of  oxygenated  blood,  and  the  active  chemical  changes 
going  on  in  the  part.  The  swelling  is  the  result  of 
the  liypersemia  and  exudation. 

There  is  no  new  anatomical  factor  in  inflammation. 
It  is  an  exaggeration  of  the  normal  physiological 
forces ;  for  in  health  the  calibre  of  the  blood-vessels  is 
frequently  varying,  exudation  of  fluids  by  osmosis  is 
in  constant  process,  and  the  white  blood-corpuscles 
habitually  wander  to  and  from  their  vascular  abodes. 
The  stimulus  is  more  intense  than  natural,  and  the 
changes  induced  less  controlled ;  and  one  phase  of 
nutrition  is  substituted  for  another,  as  when  cartilage 
cells  expend  their  energy  in  growth  and  multiplication 
at  the  expense  of  the  elaboration  of  chondrin.     The 


Chap.  I.]         Inflammation  and  Abscess.  3 

first  thinsf  noticed  at  the  seat  of  irritation  is  contraction 
of  the  vessels  rapidly  followed  by  dilatation,  then  stasis 
gradually  sets  in,  partly  from  this  dilatation,  partly  from 
the  tendency  of  the  white  corpuscles  to  cling  to  the 
walls  of  the  vessels,  increasing  the  "  still  layer."  The 
walls  of  the  capillaries  being  formed  of  protoplasmic 
cells,  held  together  by  a  soft  ground  substance,  allow 
of  the  ready  passage  of  leucocytes  through  them. 
These  bodies  may  be  seen  in  different  stages  of  transit, 
their  amoeboid  offshoots  always  being  directed  from 
the  lumen  of  the  vessel.  Whether  they  pass  through 
open  spaces  or  stomata  between  the  epithelioid  cells, 
or  make  channels  for  themselves,  is  not  certain. 

Cornil  and  Hanvier  assert  that  minute  openings 
through  which  the  leucocytes  have  passed  can  be 
shown  by  the  aid  of  nitrate  of  silver,  but  this  view  is 
highly  speculative. 

Having  cleared  the  vessels  they  make  off  into  the 
surrounding  tissues,  and  collect  in  groups,  attracted 
probably  by  the  fixed  corpuscles.  It  was  this  aggTe- 
gation  that  led  Yirchow  to  believe  that  the  small 
groups  of  cells  were  derived  from  segmentation  of  the 
connective  tissue  corpuscles.  In  some  tissues  (e.^., 
cartilage)  this  does  occur,  for  the  cartilage  cells  may 
be  seen  in  different  stages  of  growth  and  multiplica- 
tion ;  the  nuclei  enlarge,  and  the  protoplasm  swells  up, 
division  ensues,  and,  the  capsules  being  dissolved,  the 
broods  of  cells  are  set  free,  and,  joining  adjacent  groups, 
a  layer  of  embryonic  tissue  is  formed  on  the  surface. 
As  to  how  far  this  happens  in  other  forms  of  connective 
tissue,  authors  differ.  In  bone  the  corpuscles  appear 
perfectly  passive,  even  when  the  lacunse  are  opened 
up  by  absorption.  In  the  cornea  and  areolar  tissue 
the  great  majority  of  the  cells  have  wandered  from 
the  vessels. 

Red  corpuscles  also  traverse  the  walls  of  the 
capillaries,  but  not  by  amoeboid  movements.     They 


4  Surgical  Pathology.  [chap.  i. 

are  driven  through  by  the  intravascular  pressure,  the 
change  in  walls  of  the  vessels  and  the  previous  passage 
of  leucocytes  favouring  this  transportation. 

With  the  diapedesis  of  leucocytes  there  is  rapid 
exosmosis  of  serum  containing  albumin,  and  one  or 
more  of  the  factors  of  fibrin,  either  plasmin,  or 
fibrinogen  which  unites  with  the  globulin  of  the  cells 
outside  the  vessels,  probably  under  the  influence  of  a 
ferment.  Fibrin,  as  such,  does  not  exude  from  the 
vessels. 

In  the  exudation  is  a  quantity  of  mucin.  This 
has  either  escaped  from  the  blood  stream  or  it  is 
derived  from  a  mucoid  transformation  of  the  protoplasm 
of  the  cells.  It  is-  best  seen  in  discharges  from 
inflamed  mucous  membranes,  in  the  glairy  secretion 
from  some  ulcers,  and  in  the  layer  of  embryonic 
tissue  on  the  surface  of  articular  cartilage  in  white 
swelling.  There  are  important  changes  in  the  tissues 
themselves;  the  intercellular  matrix,  whether  fibrillated 
or  homogeneous,  liquefies  from  mucoid  softening  (Rind- 
fleisch).  The  epithelioid  cells  of  the  blood-vessels 
swell,  and  help  to  obstruct  the  lumen  ;  and  thus,  aided 
by  the  pressure  from  without^  and  the  adhesion  of 
leucocytes  to  the  interior  of  the  vessels,  thrombosis 
ensues.  Even  yet  resolution  may  happen,  but  a 
step  farther  takes  us  to  actual  destruction  of  tissue  by 
suppuration  or  gangrene. 

Scrapings  from  an  acutely  inflamed  tissue  contain 
cells  of  different  size  and  form  : — 

{a)  Embryonic,  with  a  single  nucleus. 

(6)  Pus  cells  in  which  the  nuclei,  varying  from 
two  to  five,  are  brought  into  relief  by  the  action  of 
acetic  acid,  which  clears  up  the  albuminoid  particles 
that  render  the  cells  granular. 

(c)  The  so-called  compound  inflammatory  cor- 
puscles of  Gluge  are  only  ordinary  cells,  enlarged  and 
loaded  with  fat  molecules ;  they  are  most  plentiful  in 


Chap.  I.]        Inflammation  and  Abscess.  5 

tissues  rich  in  fatty  matter,  and  hence  are  seen  in 
numbers  in  softening  of  the  brain  and  spinal  cord. 

{d)  Multinucleated  niofcher-cells. 

Filaments  of  fibrin  are  also  seen  enclosing  the  cells 
in  their  meshes,  and  if  the  specimen  have  been 
hardened,  coagulated  strings  of  mucin  are  present. 

The  majority  of  the  cells  are  undoubtedly 
migratory  corpuscles  that  have  escaped  from  the 
blood-vessels ;  some  are  derived  from  endogenous 
formation  and  subsequent  dissociation,  as  in  inflam- 
mation of  cartilage  and  mucous  membranes ;  and  a 
feW;  perhaps,  are  obtained  by  gemmation  and  fission 
of  multinucleated  masses  of  protoplasm.  Cohnheim 
supports  the  doctrine  of  migration  pure  and  simple ; 
Cornil  and  Ranvier  maintain  that  segmentation  of 
connective  tissue  corpuscles  is  an  important  factor  in 
the  production  of  cells. 

Inflammation  may  terminate  in  resolution  or 
absorption,  organisation  or  new  formation,  or  in  death 
of  the  tissue  by  suppuration,  gangrene,  or  caseation. 

Reigolution. — Some  of  the  cells  pass  back  into 
the  blood-vessels,  others  undergo  molecular  disintegra- 
tion and  capillary  absorption  by  the  lymphatics, 
whilst  a  few  may  remain  as  fixed  connective  tissue 
corpuscles.  The  fibrin  becomes  granular,  it  disinte- 
grates, and  is  then  removed.  The  same  change  occurs 
in  any  capillary  thrombi  that  have  formed.  The 
endothelial  cells  of  the  capillaries  shrink  to  their 
former  size,  or,  if  degenerated  past  repair,  are  replaced 
by  others.  The  vitality  of  the  contractile  walls  of 
the  capillaries  and  arterioles  is  re-established,  and  the 
vessels  assume  their  proper  calibre.  It  may  be  here 
remarked  that  the  expression  "  venous  absorption  "  is 
often  used  erroneously  ;  of  course  the  walls  of  veins 
are  permeable  to  fluids,  and  leucocytes  may  traverse 
theiji ;  but  still  the  chief  part  of  absorption  is  capil- 
lary, be  it  blood  vascular,  or  lymphatic. 


6  Surgical  Pathology.  [Chap.  i. 

Org'anisatioii. — Should  the  inflammation  be 
prolonged,  and  moderate  in  degree,  organisation  takes 
place  in  the  exudation  without  visible  loss  of  tissue. 
JSTew  blood-vessels  are  formed  by  a  looping  of  the  old 
ones,  the  softened  walls  of  the  capillaries  allowing 
protrusion  here  and  there.  The  channels  of  contiguous 
offshoots  merge  by  absorption  of  the  intervening  walls 
and  so  a  vascular  network  is  established.  There  is, 
besides,  a  separate  development  of  new  vessels  in  the 
inflammatory  embryonic  tissue.  This  may  be  effected 
in  two  ways;  firstly,  by  the  loosening  and  disintegra- 
tion of  the  central  cells  of  columns,  whilst  the 
peripheral  elongate  and  become  fixed,  and  so  construct 
the  walls  of  capillaries  ;  secondly,  vasoformative  cells 
send  out  canalicular  processes  which  anastomose. 
The  cells  expand,  the  protoplasm  liquefies,  and  the 
nuclei  possibly  grow  into  the  first  blood  corpuscles. 
Be  this  as  it  may,  these  newly-built  capillaries  coalesce 
with  the  pre-existing  vessels.  Exactly  the  same 
changes  are  observed  in  the  growth  of  tumours,  such 
as  sarcomas,  the  type  of  which  is  embryonic  connec- 
tive tissue. 

This  vascularised  lymph'  constitutes  granulation 
tissne,  which  is  merely  a  mass  of  indifferent  cells, 
cemented  by  a  scanty  amount  of  ground  substance, 
and  traversed  by  capillary  blood-vessels.  It  is  termed 
granulation  tissue^  because  when  formed  on  an 
inflamed  surface  the  centrifugal  pressure  directs  the 
loops  of  vessels  in  the  path  of  least  resistance,  and  the 
exudation  corpuscles  accumulate  and  arrange  them- 
selves about  them.  The  old  tissue  disappears  before 
this  inflammatory  neoplasia,  which,  when  the  irrita- 
tion ceases,  organises  into  connective  tissue.  The 
majority  of  the  exudation  cells  disappear  by  dis- 
integration; some  travel  back  into  the  vessels,  others 
in  surface  inflammation  are  washed  off  in  the 
discharges,     and,     lastly,     a    few     persist     as    fixed 


Chap.  I.]        Inflammation  and  Abscess.  7 

co.rpuscles.  The  intercellular  substance  fibrillates  and 
contracts,  tlius  obliterating  many  of  the  vessels, 
so  that  a  scar,  which  is  at  first  more  vascular  than  the 
surrounding  tissue,  becomes  smaller  and  paler  with 
the  lapse  of  time,  and  eventually  (unless  pigmented) 
quite  white.  As  a  rule  it  is  depressed ;  but  if  the 
irritation  be  prolonged,  as  sometimes  happens  in  the 
case  of  burns,  the  cicatricial  tissue  is  so  abundant  as 
to  project  above  the  surface  as  a  keloid  mass. 

There  is  always  a  tendency  during  organisation  to 
reproduce  the  original  tissue  of  the  part,  as  will  be 
seen  when  we  come  to  treat  of  the  mode  of  union  of 
wounds.  The  more  highly  developed  the  tissue,  the 
less  does  this  tendency  become  developed  ;  thus,  in 
the  human  subject,  at  least,  the  ends  of  divided 
muscles  are  probably  cemented  by  fibrous  tissue  only, 
and  cicatrices  of  the  skin  do  not  contain  sebaceous 
or  sweat  glands. 

Suppuration. — If  this  takes  place  with  loss  of 
tissue  on  the  surface,  the  process  is  described  as 
ulceration ;  if  in  the  substance  of  tissues  or  organs, 
an  abscess  is  the  result.  We  have  only  to  suppose  an 
intensified  irritation  to  see  that  not  only  will  the 
exudation  of  leucocytes  and  liquor  sanguinis  be 
increased,  but  the  liquefaction  of  the  cells  and  inter- 
cellular substance  will  be  complete.  Moreover,  there 
will  be  extensive  occlusion  of  vessels  by  pressure 
from  without  and  coagulation  within.  The  tissues 
sufiering  acute  starvation  quickly  disintegrate.  These 
changes  are  more  rapid  if  the  inflammation  be  infec- 
tive, for  then  active  chemical  decomposition  results 
from  the  influence  of  minute  organisms — micrococci^ 
bacteria,  etc. 

Here  we  have  the  mode  of  formation  of  an 
acute  atoscess,  i.e.,  a  closed  cavity  filled  with  the 
debris  of  broken-down  tissue,  and  fluid  and  cells 
derived  from  the  vessels.     This  is  the  final  sta2;e  of  an 


8 


Surgical  Pathology. 


[Chap,  I. 


acute  inflammation.  The  wall  of  the  abscess  consists 
of  a  highly  vascular  granulation  tissue,  the  so-called 
fyogenic  mertibrane.  From  the  vessels  of  this  layer 
exudation  passes  into  the  cavity.  Add  to  this,  a 
continuous  melting  away  of  the  lining  wall  itself  as 
the   inflammation    spreads,    and   the   picture   of    an 


c- V4^ 


Fig.  1. — Suppurative  Inflammation  of  tlie  CereT3ram  ( x  250). 
The  section  was  made  half  an  inch  away  from  the  situation  of  numerous  visible 
abscesses,  a,  blood-vessels,  showing  leucocytes  collected  within  and  without 
the  walls ;  h,  "  microscopical  abscess  ; "  c,  the  same  in  the  midst  of  a  capillary 
extravasation  ;  d!,  brain  substance,  showing  delicate  fibres  and  granules,  the 
result  of  inflammatory  softening  and  fatty  degeneration.  The  normal 
histological  characters  have  disappeared. 


enlarging  abscess  is  complete.  It  may  be  noted  that 
the  suppuration  does  not  start  from  one  focus,  for 
under  the  microscope  numerous  minute  centres  of  pus 
-formation  may  be  observed  (Fig.  1).  These  micro- 
scopical abscesses  increase  in  size,  and  coalesce. 

In  addition  to  the  original  cause  of  the  inflam- 
mation there  is  the  added  tension  from  the  retained 
products  of  suppuration.  This  tension  is  afterwards 
removed  by  the  bursting  of  tlie  abscess.  The 
importance  of  early  relief  from  the  pressure,  in  order 


Chap.  I.]        Inflammation  AND  Abscess.  9 

to  check  the  destruction  of  tissue  and  the  absorption 
of  intoxicating  or  septic  material,  is  obvious. 

Blood-vessels  and  nerves  resist  the  action  of  these 
inflammatory  changes  longer  than  oth^?  tissues,  except 
tendons  and  the  calcified  framework  of  bone. 

When  an  acute  abscess  has  been  opened  its  "walls 
collapse,  and  the  granulating  surfaces  adhere  more 
or  less,  and  thus  the  suj)purating  area  is  greatly 
diminished. 

When  an  acute  abscess  is  opened,  a  thick  creamy 
fluid  escapes,  mixed  with  blood  from  ruptured  and 
divided  vessels.  The  yellowish-white  colour  is  due  to 
the  suspension  of  refractive  bodies  (pus  cells)  in  a  fluid 
termed  liquor  puris.  To  see  that  this  is  so,  we  have 
only  to  allow  the  pus  to  stand  for  a  time  in  a  glass 
vessel,  when  two  distinct  layers  will  be  observed,  the 
lower  a  yellowish-white  deposit  with  uniform  surface, 
the  upper  a  clear  fluid.  Chemical  analysis  proves  this 
fluid  to  be  practically  identical  with  liquor  sanguinis, 
which  is  no  doubt  its  source. 

If  some  of  the  lower  layer  be  examined  with  the 
microscope,  it  will  be  found  to  consist  mainly  of 
corpuscles  from  -awo*^  *^  wb^"o*-^^  ^^  ^^  rn.c)i  in 
diameter.  These  bodies  are  for  the  most  part  round, 
but  some  are  crenated  or  otherwise  misshapen.  No 
boundary  wall  can  be  seen.  They  look  cloudy  or 
granular,  from  minute  fatty  and  albuminoid  particles. 
Acetic  acid  causes  the  cells  to  swell  up  and  become 
clear.  Many  of  the  older  cells  are  coarsely  granular 
from  fat  molecules  which  are  soluble  in  ether.  The 
fat  is  chiefly  derived  from  degeneration  of  the  proto- 
plasm of  the  cells,  but  some,  probably,  has  been  taken 
up  from  the  debris  of  perished  tissue.  The  so-called 
compound  inflammatory  corpuscles  of  Gluge  are  of 
this  nature.  Pus  cells  occasionally  contain  pigment. 
There  are  also  numberless  free  granules,  the  product 
of  disintegration   of  the  cells.      Healthy  or  laudable 


lo  Surgical  Pathology.  [Chap.  t. 

pus  is  alkaline  in  reaction.  It  forms  a  viscid  gela- 
tinous mass  on  the  addition  of  liquor  potassse. 

Origin  of  pus  corpttscles. — The  majority  are 
leucocytes  that  have  migrated  from  the  blood-vessels, 
though  it  cannot  be  denied  but  that^  in  interstitial 
inflammations,  their  number  is  increased  by  prolifera- 
tion of  connective  tissue  corpuscles,  and  still  more  in 
the  discharges  from  mucous  membranes,  and  the 
exudation  from  serous  surfaces.  In  the  two  latter 
situations  there  is  a  constant  physiological  reproduc- 
tion of  cells. 

They  resemble  white  blood-corpuscles,  in  that 
whilst  living  they  possess  the  property  of  spontaneous 
movement.  Their  vitality,  however,  is  low,  and  they 
soon  become  motionless  and  degenerate.  The  fact  of 
their  containing  two  or  more  nuclei  is,  perhaps,  a 
sign  of  declining  nutritive  activity,  the  segmentation 
of  the  protoplasm  ceasing  before  that  of  the  nuclei. 

Oaiigrene. — Inflammation  is  the  most  common 
cause  of  gangrene  or  death  of  visible  portions  of 
tissue.  The  blood  current  is  obstructed  by  the 
pressure  of  the  exudation,  and  the  vessels  are  blocked 
by  coagula ;  hence  the  tissues  perish  from  acute 
starvation  before  there  is  time  for  complete  disinte- 
gration of  their  individual  elements.  In  the  necrosed 
masses  or  sloughs  the  original  structure  is  recognis- 
able. 

Caseation* — In  chronic  inflammations,  especially 
of  the  lungs,  bone,  and  lymphatic  glands,  the  exuda- 
tion, together  with  the  affected  tissue,  undergoes  fatty 
degeneration  and  disintegration,  the  more  liquid 
portion  is  absorbed,  and  a  putty-like  substance  re- 
mains ;  this  consists  chiefly  of  granular  debris,  in 
which  crystals  of  stearic  acid  and  plates  of  cholesterine 
are  formed.  The  process  often  terminates  in  calcifi- 
cation. 

It  may  be  remarked  that  the  discharge  from  gouty 


to 


Chap.  I.]       Inflammation  and  Abscess.  ii 

abscesses  is  loaded  with  what  is  often  erroneously 
sjDoken  of  as  chalky  matter,  but  which  in  reality  is 
urate  of  soda  in  the  formof  acicular  crystals,  scattered 
or  in  stellate  groups. 

Cliroiiic  inflamiiiatioii  is  the  result  of  long- 
continued  local  irritation,  or  of  some  constitutional 
weakness.  The  inherent  defect  in  nutrition  may  be 
g;eneral,  or  centred  in  certain  organs  or  tissues  ;  e.g.^ 
in  scrofula  the  bones,  joints,  lymphatic  glands,  and 
the  lungs  suflfer  most. 

The  predisposing  condition  is  called  a  diathesis. 
It  was  believed  by  the  humoral  pathologists  that  a 
special  materies  morbi  existed  in  the  blood,  and  that 
this  was  the  cause  of  the  local  disorder  ;  hence  the 
origin  of  the  expression  "  cancerous  deposit^"  malignant 
"  growths "  being  regarded  as  exudations  of  caco- 
plastic  lymph. 

On  the  other  hand,  the  solidists  laid  the  foundation 
of  all  disease  in  the  tissues  themselves,  considering  the 
blood  as  being  secondarily  affected.  We  know,  how- 
ever, that  it  is  a  "flesh  and  blood"  malady,  for  it  is 
difficult  to  conceive  how  one  can  be  affected  without 
the  other.  It  is  true  the  specific  nature  of  a  blood 
poison  may  disappear,  as  shown  by  the  failure  of 
inoculation,  and  by  the  non-transmission  of  syphilis 
from  parents  to  offspring  in  the  tertiary  stage  ;  and 
yet  how  often  do  very  grave  inflammatory  lesions 
crop  up  in  after  years.  Some  pathologists  look  upon 
these  as  sequelae  of  syphilis,  and,  in  so  far  as  a  repro- 
duction of  the  same  disease  in  others  is  concerned, 
they  may  be  ;  yet  it  cannot  be  supposed  that  the  blood 
is  free  from  taint. 

The  final  result  of  a  chronic  inflammation  turns 
mainly  upon  whether  the  latter  proceeds  from  a  local 
or  constitutional  cause.  If  purely  local  and  only 
moderately  severe,  the  lymph  organises  into  connective 
tissue  pure  and   simple,  or  with   the  admixture  of  a 


12  Surgical  Pathology.  [Chap.  i. 

more  highly-developed  product,  such  as  bone.  If 
constitutional,  there  may  be  loss  of  substance  at  one 
part  with  increase  at  another,  as  where  the  end  of  a 
bone  is  gradually  worn  away  from  softening  and 
friction,  whilst  around  it  numerous  osteophytes  are 
thrown  out ;  e.g.,  in  chronic  rheumatic  arthritis. 

When  the  individual  is  strumous,  caseation  and 
abscess  are  very  common ;  e.g. ,  in  the  cervical  glands. 

Chronic  abscess  is  also  called  congestive,  from 
the  presence  of  passive  rather  than  acute  hypersemia, 
and  cold,  from  the  fact  that  there  is  little  or  no 
elevation  of  temperature  of  the  part,  for  the  blood 
current  is  sluggish  and  the  chemical  changes  are 
not  very  active. 

It  is  often  consecutive,  as  when  cervical  glandular 
abscess  follows  caries  of  a  tooth,  or  psoas  abscess  de- 
pends upon  disease  of  the  spine.  From  the  persistence 
of  the  original  cause,  together  with  the  continued 
tension,  chronic  abscesses  frequently  attain  a  great 
size  ;  and  when  deeply-seated  and  the  resistance  of  the 
tissues  around  is  unequal^  they  follow  well-known 
anatomical  paths  j  thus,  a  spinal  abscess  may  open  at 
the  groin  or  knee,  or  even  at  the  ankle.  And,  inas- 
much as  the  line  of  least  obstruction  is  usually  in  the 
long  axis  of  the  body,  they  gravitate  to  more  dependent 
parts.  The  structures  around  become  condensed. 
The  cicatricial  tissue,  as  it  shrinks,  diminishes  its  own 
vascularity,  and  makes  the  walls  of  the  abscess  rigid, 
so  that  they  can  only  imperfectly  collapse  when  the 
cavity  is  laid  open.  As  the  contents  escajDe,  germ- 
laden  air  too  often  enters  and  leads  to  decomposition 
of  what  remains.  This  is  favoured  by  the  retention  of 
pus  in  offshoots  from  the  main  cavity.  The  badly- 
nourished  walls  are  slow  in  constructing  granulations 
for  the  obliteration  of  the  space  within,  and  are  apt  to 
absorb  infective  matter,  the  source  of  chronic  and 
acute  pyaemia.     Hence  the  force  of  Billroth's  remark, 


Chap.  II.]  Pain.  13 

when  speaking  o£  psoas  abscesses,  "  Be  thankful  for 
every  day  they  remain  closed."  Chronic  abscesses 
should  be  left  to  open  themselves,  unless  (1)  they  are 
about  to  burst,  and  the  vitality  of  the  skin  over  them 
is  threatened,  as  in  the  neck  ;  or  (2)  they  encroach 
upon  some  important  organ  or  structure,  as  in  retro- 
pharyngeal abscess  ;  or  (3)  they  would  subsequently 
open  in  a  less  advantageous  position,  as  when  a  psoas 
abscess,  having  reached  the  thigh,  still  shows  signs  of 
spreading.  The  contents  of  chronic  abscesses  vary 
much.  Sometim.es  the  fibrinous  portion  of  the  exuda- 
tion remains  in  solution ;  at  others  it  separates  in 
the  form  of  flakes  or  curds.  On  absorption  of  the 
serum  the  pus  is  reduced  to  the  consistence  of  clotted 
cream  or  of  soft  putty.  The  so-called  "  inspissated 
pus  "  is  made  up  of  fibrin  and  cells  in  a  state  of  fatty 
degeneration. 

When  the  abscess  has  formed  in  connection  with 
diseased  bone,  the  pus  contains  an  excess  of  lime 
salts,  and  not  unfrequently  minute  sequestra. 

Abscesses  arising  at  the  seat  of  a  previous  in- 
flammation are  termed  "residual"  (Paget).  The 
vitality  of  the  tissues  has  remained  defective,  and 
unable  to  cope  with  further  irritation.  The  part  is  a 
"locus  resistentise  minoris." 


CHAPTER   II. 

PAIN. 


Pain  is  always  a  symptom  of  diminished  functional, 
and,  therefore,  nutritive,  power,  whether  it  be  the 
headache  from  a  tired  brain  or  the  smarting  from 
a  scald.     We    say    functional    'power ;   for    excessive 


14  Surgical  Pathology.  [Chap.  ii. 

functional  activity  is  one  of  tlie  first  indications  of 
exhaustion  (C.  Bernard). 

It  is  purely  subjective,  and  is,  therefore,  difficult  to 
estimate ;  for  its  existence,  nature,  and  extent  can 
be  simulated,  and  it  may  appear  out  of  all  pro.- 
portion  to  the  intensity  of  any  assignable  cause.  It 
is  the  fashion  to  give  but  little  heed  to  the  suflferings 
of  hysterical  patients,  but  their  nervous  mimicry  of 
pain  is  to  them  a  real  disease. 

There  are  three  factors  in  the  production  of  pain  : 
(1)  Extrinsic  irritation,  physical  or  chemical;  (2)  in- 
herent susceptibility  of  the  implicated  nerve-centre  ; 
(3)  emotion.  It  is  well  to  assume  that  all  pain  is 
organic  (it  is  termed  functional  when  no  correspond- 
ing tissue-change  can  be  seen,  but  "cell  "  and  "  fibre" 
are  only  coarse  expressions  of  molecular  structure), 
for  then  there  will  be  no  excuse  for  considering  the 
less  obvious  cases  as  ^'idiopathic."  The  irritation 
may  be  of  peripheral  or  central  origin.  Wh-en  cen- 
tral, it  is  referred  to  the  whole  or  some  part  of  the 
area  of  distribution  of  the  corresponding  nerve. 
When  peripheral,  it  is  usually  referred  to  the  seat  of 
irritation,  but  not  rarely  to  the  terminal  part  of  some 
other  branch  of  the  same  nerve,  as  in  the  knee  when 
the  hip  is  diseased,  or  in  the  ear  when  a  tooth-pulp 
is  inflamed  3  or  the  pain  is  felt  in  some  nerve  asso- 
ciated in  function,  origin,  or  distribution,  as  when 
ascarides  in  the  rectum  lead  to  discomfort  about  the 
penis,  or  a  stone  in  the  bladder  causes  painful  tenes- 
mus. If  the  stimulus  be  applied  in  the  course  of  a 
nerve-trunk,  as  in  neuritis,  there  is  local  tenderness  to 
the  touch,  accompanied  by  pains  radiating  along  the 
derivative  branches.  In  some  cases  the  pain  is 
experienced  only  at  the  distal  end ;  e.^.,  at  the  back 
of  the  head  in  atlo-axoid  disease,  in  which  the  great 
occipital  nerve  is  caught  as  it  passes  between  the 
bones. 


Chap.  II.]  Pain.  ■  15 

In  any  case  of  localised  pain  the  nerve  should  be 
examined  as  far  back  to  its  origin  as  practicable,  and 
then  the  trunk  and  all  its  branches,  and  also  the 
associated  nerves,  taken  in  review. 

Types  of  pain. — There  are  two  primary  types  of 
pain:  (1)  continuous;  (2)  intermittent.  The  former 
is  either  aching^  which  is  symptomatic  of  tension 
beneath  very  resisting  structures,  as  in  ostitis,  peri- 
ostitis, and  subfascial  inflammation,  and  in  the  erosion 
of  vertebrae  by  an  aneurism ;  in  all  these  instances 
the  nerves  are  constantly  on  the  stretch ;  or  it  is 
smarting,  which  is  characteristic  of  surface  irritation, 
as  in  burns  and  scalds.  (Perhaps  the  latter  is  in 
reality  an  intermittent  pain,  the  impulses  succeeding 
one  another  so  rapidly  as  to  make  it  appear  con- 
tinuous, the  analogy  being  that  of  tonic  to  clonic 
spasm.) 

Intermittent  pain  is  either  neuralgic  or  throbbing. 
In  the  former  case  it  is  indicative  of  recurring  dis- 
charges of  a  diseased  nerve-centre,  as  in  the  "  lighten- 
ing pains "  of  locomotor  ataxia ;  or  of  varying 
vascular  tension,  as  when  the  pulp  of  a  tooth  is 
inflamed. 

In  throbbing  pain,  the  nerve  endings  are  over- 
sensitive from  inflammation,  and  the  tissues  are 
softened,  and  so  allow  considerable  latitude  for  expan- 
sion of  the  vessels  ;  hence  the  pulsation  of  the  arteries 
is  felt  by  the  patient,  and  this  gives  the  peculiar 
character  to  the  pain.  It  is  suggestive  of  the  forma- 
tion of  pus.  The  shooting  pains  felt  in  cancer  are 
probably  due  to  the  implication  of  fresh  nerve-fibres 
by  the  growth.  A  combination  of  continuous  and 
spasmodic  pain  is  well  seen  in  the  passage  of  a  biliary 
or  renal  calculus,  the  continuous  character  depending 
upon  the  resisting  nature  of  the  walls  of  the  duct, 
and  the  spasmodic  upon  the  intermittent  contractions 
of  the  muscular  coat. 


1 6  Surgical  Pathology.  [Chap.  hi. 

Effects  of  pain  on  nutrition. — There  can  be 
no  doubt  but  that  nutritive  changes  are  more  marked 
where  pain  is  severe,  the  atrophy  of  the  muscles  in 
hip-joint  disease  being  proportionate  {ceteris  paribus) 
to  the  patient's  suffering ;  for  local,  like  general,  dis- 
turbance of  rest  prevents  the  natural  repair  of  tissues 
wasted  during  activity. 

Keflex  subdual  of  pain. — As  pain  can  be 
induced  by  reflex  action,  so  it  may  be  subdued,  hence, 
the  use  of  powerful  local  sedatives  applied  to  the  skin  ; 
e.g.,  in  the  deep-seated  inflammation  of  joints.  The 
relief  given  by  counter-irritants,  though  apparently 
contradicting  this  theory,  really  supports  it,  for  the 
peripheral  irritation  produces  an  exhaustion  of  the 
nerve-centre,  and  makes  it  less  sensitive  to  a  stimulus 
applied  to  the  deep-seated  nerves. 


CHAPTER   III. 

ULCERATION. 

Ulceration  is  a  surface  solution  of  continuity  from 
molecular  death  of  the  tissues.  In  this  way  it  differs 
from  gangrene,  or  molar  death.  (Molecular  disinte- 
gration is  not  limited  to  ulceration,  for  it  is  met  with 
in  primary  interstitial  degeneration.) 

Whatever  the  primary  cause  of  ulceration  may  be, 
there  is  at  some  period  inflammation  of  the  part ; 
thus,  in  cancrum  oris  the  most  important  factor  is 
progressive  capillary  thrombosis,  but  the  coagula 
irritate  the  walls  of  the  vessels,  and  cause  them  to 
inflame,  and  the  inflammation  spreads  to  the  tissues 
around.  An  ulcer  may  begin  as  a  surface  lesion,  or 
be  the  consequence  of  suppuration  beneath  the  skin 


Chap.  III.]  Ulceration.  17 

or  a  mucous  membrane.      An  abscess  may  be  defined 
as  a  closed  ulcer. 

Oaiises  of  iilceration. — The  irritation  is  either 
physical  or  chemical,  or  both ;  in  any  case  the  result 
is  vascular  dilatation  and  exudation,  and  the  tension 
thus  increased  acts  as  a  further  cause  of  inflammation, 
by  obstructing  the  flow  of  blood  and  stretching  the 
tissues.  As  physical  causes,  we  may  mention  wounds, 
continued  pressure  and  friction,  as  in  bed  sores, 
extreme  heat  and  cold,  and  rupture  of  a  varicose 
vein.  Chemical  irritants  may  be  applied  locally  to 
the  surface  or  beneath  the  skin,  or  they  may  be 
diffused  in  the  circulation ;  e.y.,  the  specific  poisons  of 
typhoid  and  syphilis. 

Mode  of  formatioo  of  a  simple  ulcer. — We 
will  take  the  case  of  the  heel  pinched  by  a  shoe.  In 
the  first  place,  the  friction  causes  dilatation  of  the 
vessels  and  exudation  of  liquor  sanguinis  and  leu- 
cocytes ;  hence  the  redness  and  swelling.  The  exuda- 
tion increases  to  such  an  extent  that  the  tissues  can 
no  longer  retain  it  wdthin  their  interstices,  and  some, 
escaping  between  the  cells  of  the  softened  epidermis, 
oozes  from  the  surface,  as  in  eczema.  If  it  be  more 
rapid,  the  epidermis  is  raised  in  the  form  of  a  bleb. 
In  the  meantime  the  cells  of  the  rete  are  being 
excited  to  greater  formative  activity.  They  divide 
and  subdivide,  but  no  longer  undergo  cornification. 
The  embryonic  corpuscles  thus  derived  mingle  with 
the  discharge  from  the  vessels.  The  epidermis 
becomes  soddened,  and  is  swept  away  by  the  outward 
current,  or  is  brushed  off*  by  the  slightest  friction. 
In  this  way  the  tips  of  the  papillse  become  exposed, 
and  the  ulcer  is  fully  formed.  The  papillse  themselves 
are  rendered  succulent  by  the  exudation  and  mucoid 
softening  of  their  constituent  elements.  This,  to- 
gether with  the  cellular  infiltration,  causes  them  to 
lose  their  natural  histological  features.  They  are,  in 
c 


1 8  Surgical  Pathology.  [Chap.  hi. 

fact,  converted  into  granulation  tissue.  The  exuda- 
tion now  Hows  from  the  surface  in  the  form  of  pus. 
The  extent  of  the  changes  in  the  subcutaneous  tissue 
varies  as  the  severity  of  the  inflammation. 

The  stages  of  an  ulcer. — There  are  two  oppo- 
site processes  in  the  course  of  an  ulcer,  destruction 
and  repair.  These  pass  so  gradually  into  each  other 
that  it  is  diffi<5ult  to  say  where  one  ends  and  the 
other  begins.  But,  during  the  time  that  elapses 
from  the  commencement  to  the  close,  an  ulcer  may  be 
said  to  pass  through  three  stages  :  (1)  spreading ; 
(2)  stationary ;  (3)  healing.  These  are  sometimes 
erroneously  described  as  varieties  of  ulcers,  whereas 
they  really  refer  to  their  condition  at  a  given 
time. 

Spreadiog-  stag-e. — This  is  well  exemplified  in 
a  soft  chancre.  The  same  changes  that  led  to  the 
formation  of  the  ulcer  are  still  in  active  progress. 
The  margin  is  surrounded  by  a  zone  of  hypersemia, 
is  more  or  less  swollen,  is  sharply  defined  and  steep, 
and,  if  the  ulceration  be  spreading  more  rapidly  in 
the  subcutaneous  tissue  than  in  the  skin,  it  is  under- 
mined. As  to  the  hase.,  there  will  probably  be  no  granu- 
lations in  the  floor  of  the  ulcer,  for  the  inflammatory 
neoplasia  is  destroyed  too  quickly  to  allow  of  its 
assuming  the  granular  form.  It  has  a  gray,  or 
yellowish-gray  appearance,  and  is  covered  with  pus 
and  the  debris  of  the  disintegrating  tissues.  The 
colour  is  due  to  fatty  matter  and  softened  blood- 
clot,  for  thrombosis  precedes  the  loss  of  vitality  and 
subsequent  dissolution ;  and  this  is  the  reason  why 
haemorrhage  is  not  more  common.  If  the  ulceration 
be  very  active,  the  cellular  tissue  is  destroyed  before 
the  more  resisting  structures,  such  as  vessels  and 
nerves,  have  had  time  to  melt  away  into  mole- 
cular debris.  The  base  then  appears  somewhat  floc- 
culent  and   the  margin  fringed ;  in  fact,  gangrene  is 


Chap.  III.]  Ulceration:  19 

added  to  true  ulceration.  There  is  usually  consider- 
able pain  in  the  part. 

Stationary  period. — This  is  best  observed  in 
chronic  varicose  ulcers  of  the  leg,  whose  margins  are 
indurated  by  condensation  of  the  exudation.  This 
always  takes  place  when  the  healing  is  long  deferred. 
The  margin  is  usually  thickened  and  rounded.  It  is 
rarely  so  precipitous  or  undermined  as  when  the 
ulcer  is  spreading,  nor  is  the  surrounding  inflammatory 
redness  so  marked.  The  base  consists  of  small,  un- 
healthy, or  pale  exuberant  granulations.  The  dis- 
charge is  subject  to  much  variation  as  to  character 
and  amount ;  at  times  it  is  scanty  and  highly  fibrinous, 
and  coagulates  on  the  surface ;  or,  again,  it  is  thin 
and  serous  ;  or  these  conditions  may  alternate. 

The  causes  of  ulcers  being  stationary  are  (1) 
obstruction  to  the  return  of  blood ;  e.g.,  where  the 
veins  are  varicosed  (the  granulations  are  then' often 
large  and  oedematous)  ;  (2)  continued  slight  irritation, 
as  in  an  issue ;  (3)  fixation  of  the  margin  to  some 
rigid  underlying  structure,  which  prevents  cicatrisa- 
tion, as  in  ulcers  over  the  malleoli  and  crest  of  the 
tibia,  and  over  tendons  where  there  is  movement  in 
addition. 

Healiug'period. — Under  ordinary  circumstances, 
when  the  source  of  irritation  has  been  removed  the 
ulcer  begins  to  heal.  In  the  first  place,  the  inflamma- 
tion tends  to  resolution,  the  blood-vessels  contract, 
there  is  less  exudation  from  the  surface  of  the  sore, 
and  that  efiused  into  the  interstices  of  the  tissues  is 
re-absorbed.  The  margin  is  fairly  on  a  level  with,  or 
slopes  towards,  the  base.  Two  zones  may  be  dis- 
tinguished ;  an  outer,  where  the  epidermis  is  heaped- 
up,  opaque,  white,  and  soddened  ;  and  an  inner,  more 
transparent,  where  the  epithelial  cells  are  only  one  or 
two  deep,  on  the  surface  of  the  granulation  tissue. 
It  has   a  slightly  clouded  purplish  hue.     There  is  a 


2  0  Surgical  Pathology.  [Chap.  hi. 

gradual  transition  from  one  zone  to  the  other.  The 
base  is  made  up  of  bright  florid  granulations  dis- 
charging healthy  pus. 

Histology  of  the  gi^aBiiilatioiis. — The  granu- 
lations consist  of  migratory  leucocytes  held  together 
by  a  scanty  fibrinous  intercellular  substance.  The 
deeper  cells  have  greater  cohesion  than  the  more 
superficial  ones.  Those  immediately  on  the  surface 
are  floated  off  by  the  fluid  that  bathes  it,  and  are  then 
known  as  pus  corpuscles.  Capillary  blood-vessels 
traverse  the  cellular  mass.  They  form  overarching 
loops  with  the  convexity  towards  the  surface.  This 
arrangement  is  based  upon  the  plan  laid  down  in 
healthy  skin  and  mucous  membrane.  It  becomes  more 
marked  in  the  granulations  of  an  ulcer,  on  account  of 
the  pressure  of  the  outflowing  stream  of  exudation  and 
the  diminished  resistance  of  the  softened  tissues. 
Granulations  contain  no  lymphatics,  and  probably  no 
nerves  of  new  formation. 

Cicatrisation  of  an  nicer. — This  is  quite  as 
essential  to  the  healing  as  the  precedent  growth  of 
granulations.  Many  of  the  cells  undergo  fatty 
degeneration,  and  are  absorbed;  some  probably  return 
to  the  blood-vessels  by  their  amoeboid  movements ;  the 
remainder  develop  into  fixed  connective  tissue  cor- 
puscles. As  the  inflammation  subsides  the  deeper  cells 
elongate  and  become  fusiform,  and  the  intercellular 
substance  increases  and  fibrillates.  This  highly  vascular 
and  corpuscular  connective  tissue  at  length  contracts, 
and  in  so  doing  obliterates  many  of  the  vessels  ;  nor 
does  it  stop  until  the  scar  is  denser  and  whiter  than 
the  normal  tissue  around.  Several  months  elapse  ere 
the  process  is  completed.  As  the  ulcer  heals  the 
epithelial  cells  grow  inward  over  the  granulations, 
which  at  the  margin  cease  to  secrete  pus.  Eventually 
the  entire  surface  is  "skinned  over."  During  this 
time   the   contraction   may  be  so  great  as  to  cause 


Chap.  III.]  Ulceration.  21 

serious  deformity,  especially  where  wide  tracts  of  skin 
have  been  destroyed,  as  in  extensive  burns.  The  chin 
may  be  drawn  down  and  fixed  to  the  sternum. 
Ectropion  or  eversion  of  the  eyelid  often  follows  the 
cicatrisation  of  an  ulcer  of  the  face.  In  annular  ulcer 
of  the  leg,  there  being  no  skin  to  glide  in  the  circum- 
ference of  the  limb,  the  effect  of  contraction  in  this 
direction  is  to  keep  up  continued  irritation  of  the 
granulation  tissue,  hence  these  ulcers  rarely  heal. 

Reprodiietion  of  epithelmm. — As  the  ulcer 
heals  the  epithelium  grows  over  the  granulations. 
The  cells  are  chiefly  derived  from  segmentation  of 
those  at  the  margin,  but  it  is  possible  that  some  are 
furnished  by  the  granulations.  Now  and  then  islets 
spring  up  at  a  distance  from  the  marginal  zone  of 
epithelium ;  in  these  cases  the  cells  of  the  rete  must 
have  escaped  destruction  by  the  ulceration,  for  there 
is  nothing  to  show  that  they  arise  spontaneously  from 
the  granulations  exce]:)t  under  the  immediate  influence 
of  pre-existing  epithelium. 

Kever din's  skin  gi^aftmg'. — All  that  is  neces- 
sary is  to  transplant  snippings  from  the  deep  proto- 
plasmic cells  of  the  rete  to  the  healthy  granulations, 
and  to  fix  and  protect  them  there.  This,  by  furnishing 
fresh  centres  of  cicatrisation,  greatly  hastens  the 
healing,  and  by  so  doing  lessens  the  after  contraction. 
These  grafts  are  sufiiiciently  fixed,  after  a  few  days,  to 
hold  of  themselves. 

IVoineiielatiire. — The  ordinary  features  of  an 
ulcer  may  be  so  modified  as  to  give  to  the  condition  a 
Fpecial  appellation.  This  may  arise  from  a  local 
hindrance  to  healing,  or  depend  upon  some  constitu- 
tional taint ;  or  both  causes  may  act  at  the  same  time. 

Symptomatic  ulcers  are  those  that  point  to  a 
disease  of  wider  distribution  than  the  part  immediately 
under  observation,  such  as  syphilis,  scrofula,  lupus, 
epithelioma,    venous    varicosity,  etc.       In    describing 


2  2  Surgical  Pathology.  [Chap.  iii. 

ulcers  it  is  usual  to  direct  attention  to  the  granulations 
that  do  or  should  form  the  base,  the  edge,  the  tissues 
around,  including  the  vessels  that  supply  and  return 
the  blood,  and  lastly  the  discharge.  The  particular 
designation  of  an  ulcer  is  drawn  from  the  state  of  the 
part  that  shows  the  widest  departure  from  the  normal; 
hence  we  speak  of  "diseases  of  the  granulations,"  of 
an  "undermined"  or  "indurated  margin,"  and  so 
forth.  But  observation  that  is  limited  to  any  one  of 
these  is  too  exclusive,  for  it  cannot  be  said  that  an 
ulcer  is  healthy  as  regards  the  edge,  and  not  so  in 
respect  to  the  base ;  the  whole  should  be  passed  in 
review. 

L.ocality  of  ulcers. — There  are  three  factors 
that  determine  this  :  (1)  Exposure  to  injury,  whether 
it  be  from  direct  violence  or  continued  irritation  ;  (2) 
the  local  effect  of  a  materies  morbi,  either  at  the  seat 
of  inoculation,  or  in  some  remote  part,  or  both ;  thus 
syphilis  leads  to  primary,  secondary,  and  tertiary 
ulceration.  Typhoid  fever  attacks  the  intestine,  and 
sometimes  the  throat ;  scarlet  fever  and  diphtheria 
the  throat ;  and  small-pox  the  skin ;  (3)  inherent  or 
acquired  weakness  of  certain  tissues,  or,  as  it  is 
termed,  the  liability  or  predisposition  to  this  or  that 
form  of  ulceration ;  e.g.,  lupus  is  very  prone  to  occur 
in  the  face,  and  tubercular  disease  in  the  small 
intestine.  Varicose  ulcers  are  practically  confined  to 
the  lower  extremities. 

Bearing  these  facts  in  mind,  we  have,  apart  from 
the  characters  of  the  ulcer,  a  valuable  aid  to  regional 
diagnosis ;  thus  the  majority  of  ulcers  of  the  leg  are 
either  varicose,  traumatic,  or  syphilitic.  The  widely 
destructive  ulcers  of  the  face  are  due  to  lupus,  syphilis, 
rodent  ulcer,  and  epithelioma.  In  the  mouth  and 
rectum  malignant  disease,  syphilis,  and  local  irritation 
take  the  lead.  In  the  small  intestine  typhoid  fever 
and  tuberculosis  head  the  list.     In  the  case  of  the 


Chap.  III.]  Ulceration.  23 

loenis  the  inquiry  is  very  limited  after  excluding 
chancres,  herpes,  and  epithelioma. 

Again,  in  the  leg  most  ulcers  begin  on  the  front 
aspect,  and  this  is  notably  the  case  in  the  traumatic 
and  varicose  varieties.  Yaricose  ulcers  are  nearly 
always  found  in  the  lower  third;  syphilitic  fre- 
quently about  the  knee ;  whilst  strumous  are 
more  confined  to  the  skin  over  the  epiphyses  and 
about  the  foot,  since  these  parts  are  very  subject  to 
caries. 

Diseases  of  tlie  granulations. — 1.  Croupous; 
2.  Fungous ;  3.   Hsemorrhagic ;  4.   Diphtheritic. 

1.  Croupous  disease, — The  only  way  in  which 
the  condition  resembles  croup  is  in  the  existence 
of  a  rind  covering  the  base  of  the  ulcer.  This  may  be 
likened  to  a  false  membrane,  for  it  can  be  peeled  off 
with  the  forceps.  Its  presence  is  compatible  with 
good  general  health,  and  it  is  not  contagious.  It  has 
a  bright  yellow  or  grayish  yellow  colour.  Under  the 
microscope  it  is  seen  to  be  composed  of  indifferent  cells 
firmly  held  together  by  a  highly  fibrinous  material. 
The  formation  of  this  probably  depends  upon  a  purely 
local  cause.  There  is  an  alteration  in  the  nutrition  of 
the  granulations,  but  whether  the  result  of  this  is  a 
degenerative  change  in  the  cells  themselves,  or  a 
modified  exudation  of  liquor  sanguinis,  is  uncertain. 
We  know  that  it  can  be  artificially  produced  by  the 
repeated  application  of  a  sharp  irritant,  such  as 
blistering  fluid,  and  that  after  a  time  it  will  disappear 
of  itself.  The  actual  cause  of  its  spontaneous  origin  is 
to  be  sought  perhaps  in  the  properties  of.  the  chemical 
products  of  decomposition  of  the  exudation  that 
escapes  from  the  vessels  of  the  granulations.  The 
rational  treatment  of  the  ulcer  is  to  remove  all  sources 
of  irritation  by  protecting  it  from  friction,  and  counter- 
acting the  effects  of  unhealthy  discharges  by  the  use 
of  detergent  dressings.     The  fibrinous  rind  is  quickly 


24  Surgical  Pathology.  [Chap.  hi. 

reformed,  hence  its  simple  removal  will  not  suffice  for 
a  cure. 

2.  Fungous  disease. — There  are  two  forms  of 
this,  the  one  depending  upon  an  interference  with  the 
return  of  blood  from  the  part  where  it  may  be  con- 
sidered much  after  the  nature  of  a  local  oedema;  the 
other  upon  excessive  formative  activity  and  defec- 
tive organising  power  of  the  granulations,  kept  up  by 
continued  slight  irritation.  Yery  often  both  causes 
work  together. 

The  granulations  are  large,  pale,  and  gelatinous, 
and  secrete  a  thin  muco-purulent  matter.  They  may 
be  so  exuberant  as  to  rise  for  some  distance  above  the 
level  of  the  margin  of  the  ulcer,  and  even  to  overlap 
it.  They  have  but  little  tendency  to  recede  of  them- 
selves, and  this  is  notably  the  case  when  the  veins  of 
the  part  are  dilated  and  varicosed,  and  the  margin  of 
the  ulcer  indurated.  Besides  the  excess  of  watery 
exudation,  there  is  softening  of  the  granulations  from 
mucoid  degeneration ;  this  is  shown  by  the  nature  of 
the  discharge.  The  treatment  consists  in  removing  all 
obstacles  to  the  return  of  blood  from  the  ulcer,  by 
attention  to  position,  and  artificial  support  of  the  veins, 
and  in  applying  pressure  directly  to  the  granulations ; 
this  relieves  the  fulness  of  the  capillaries,  and  by 
making  the  extravascular  greater  than  the  intravascu- 
lar tension,  tends  to  reverse  the  osmotic  current,  or,  in 
more  familiar  but  less  explicit  terms,  favours  absorp- 
tion. The  cells  of  the  granulations,  robbed  too  of  a 
part  of  their  blood  supply,  undergo  fatty  degeneration 
prior  to  removal.  Healing  may  be  hastened  by  de- 
stroying the  superficial  granulations  by  an  escharotic. 
Stimulant  applications,  as  we  have  seen,  promote  a  more 
fibrinous  or  plastic  exudation,  and  this  gives  better 
support  to  the  vessels.  Astringents  act  both  as  irri- 
tants and  desiccantsj  they  diminish  the  calibre  of  the 
granulation  capillaries  more  by  extracting  water  than 


Chap.  III.]  Ulceration.  25 

Ly  increasing  the  functional  contractility  of  the  walls 
of  the  vessels. 

3.  Hsemorrlftsigic  condition  of  tbe  grsiiiiila- 
tionis. — This  may  be  solely  due  to  the  tension  on  the 
venous  side  of  the  capillaries  being  so  great  as  to  burst 
the  delicate  walls  of  the  latter,  as  when  the  veins  of 
the  leg  are  dilated  and  varicosed,  or  the  veinlets 
returning  from  the  ulcer  are  compressed  by  its  callous 
indurated  walls,  and  perhaps  thrombosed  as  well.  On 
the  other  hand,  the  capillaries  may  be  unable  to  with- 
stand the  normal  pressure,  owing  to  a  primitive  weak- 
ness in  construction  or  fatty  degeneration  of  their 
walls. 

Then  there  are  some  ulcers  that  are  essentially 
hsemorrhagic,  e.g.^  those  due  to  malignant  disease, 
scurvy,  etc.  The  result  of  haemorrhage  is  to  delay 
the  healing,  esi:»ecially  when  it  occurs  in -the  depths 
of  the  granulations,  as  well  as  on  the  surface,  for 
vessels  are  not  only  destroyed  by  rupture,  but  some 
are  obliterated  by  the  compression  of  the  extravasated 
blood. 

In  extensive  burns  the  granulations  readily  bleed  ; 
even  the  removal  of  external  support  involved  in 
changing  the  dressings,  or  the  mere  dependent  position 
of  the  part^  may  be  sufficient  to  effect  this. 

4.  Diphtlieria  of  tlie  g'rauulatious. — This 
phrase  is  unfortunate  in  its  application  to  the  condition 
of  an  ulcer,  for  it  implies  that  the  latter  is  necessarily 
the  seat  of  true  diphtheria,  either  by  direct  inoculation 
with  the  virus  of  that  specific  fever,  or  by  infection  of 
the  wound  through  the  blood.  JSTo  doubt  an  ulcer 
offers  a  favourable  surface  for  absorption,  and  especi- 
ally when  it  is  spreading  ;  and  there  is  no  reason  why 
there  should  be  immunity  from  the  action  of  the 
poison  of  diphtheria,  nor  why  we  should  decline  to 
recognise  a  true  diphtheritic  disease  of  the  granulations. 
But  what  we  wish  to  insist  upon  is,  that  the  expression 


26  Surgical  Pathology.  [Chap.  hi. 

''diphtheria  of  wounds,"  as  commonly  employed,  is 
used  to  describe  in  general  terms  the  local  appearances 
that  closely  resemble  those  following  true  diphtheritic 
infection,  without  the  expressed  or  implied  belief  that 
in  all  cases  such  infection  has  really  happened.  It. 
would  certainly  be  better  to  restrict  the  application  to 
the  specific  disease,  diphtheria,  but  long  usage  stands 
in  the  way  of  this.  The  difficulty  in  arriving  at  a 
satisfactory  nomenclature  lies  in  the  fact  that  many 
organisms  possess  the  property  of  causing  similar  local 
manifestations,  although  each  one  differs  from  the  rest 
in  its  real  nature.  Some  pathologists  consider  the 
disease  in  question  as  identical  with  hospital  gangrene. 
Billroth,  whilst  admitting  a  resemblance  between  the 
two  affections,  says  they  are  quite  distinct  from  one 
another,  and  expresses  the  belief  that  each  one  is 
dependent  upon  a  specific  poison.  This  coincides  with 
our  own  views.  Diphtheria,  when  it  attacks  an  ulcer, 
gives  rise  to  excessive  fibrinous  exudation,  that  infil- 
trates the  granulations,  and  forms  a  thick  rind  on  the 
surface.  The  vessels  of  the  granulations  become 
thrombosed,  and  this  aids  in  the  molecular  disintegra- 
tion. The  tissues  around  show  inflammatory  hyper- 
semia,  and  are  in  their  turn  destroyed. 

Other  conditions  of  an  ulcer  : 

1.  Eiiflaiuma.tiou. — The  usual  signs  of  inflam- 
mation are  seen  in  the  skin  around,  and  in  addition 
there  is  often  some  catarrhal  exudation,  and  occasion- 
ally a  number  of  small  acute  eczematous  ulcers.  All 
this  will  depend  upon  the  severity  and  duration  of  the 
inflammation.  If  the  ulcer  has  been  previously 
healing,  the  process  is  arrested,  and  the  marginal  zone 
of  newly  formed  epithelium  is  destroyed.  The  granu- 
lations lose  their  florid  hue  and  change  to  ashen  gray. 
The  superficial  layer  at  least  is  destroyed,  for  the  cir- 
culation in  the  delicate  capillary  loops  is  quickly 
arrested.     After  this  the  surface  of  the  ulcer  is  more 


Chap.  III.]  Ulceration.  27 

or  less  smooth,  and  covered  with  pus  and  the  debris 
of  broken-down  granulations.  There  are  great  pain 
and  tenderness.  Should  the  inflammation  continue, 
the  ulcer  spreads. 

2.  Irritable  ulcer. — An  inflamed  ulcer  is  neces- 
sarily an  irritable  one,  but  the  burning  pain  may  be 
out  of  proportion  to  any  visible  cause.  It  is  in  some 
way  due  to  the  state  of  the  nerves  supplying  the  part, 
and  is  not  always  co-extensive  with  the  ulcerated  sur- 
face, but  may  be  limited  to  a  particular  part  corre- 
sponding to  the  known  distribution  of  a  nerve.  By 
some  it  is  supposed  that  the  nerve-fibres  are  exposed 
in  the  floor  of  the  ulcer.  Billroth  suggests  that  they 
may  undergo  bulbous  enlargement,  like  the  nerve- 
trunks  involved  in  the  cicatrix  of  an  amputation 
stump ;  but  this  is  mere  surmise.  It  seems  to  us  that 
the  nerve-fibres  are  subject  to  irritation  in  one  of  two 
ways  :  either  chemically  by  the  discharge,  or  physi- 
cally by  being  stretched  in  the  base  or  margin  of  the 
ulcer.  The  latter  is  more  probable^  since  it  accords 
with  the  fact  that  the  pain  is  sometimes  limited  to  a 
certain  area.  There  is  usually  evidence  of  slight  in- 
flammation. The  granulations  are  very  small,  and 
the  secretion  scanty.  Whilst  this  condition  lasts  re- 
pair is  at  a  standstill.  It  is  noteworthy  that  circum- 
cision of  the  ulcer,  or  subcutaneous  division  of  the 
aflected  nerve,  may  at  once  remove  the  pain,  and  with 
it  the  cause  that  prevents  healing  (Hilton). 

3.  Callous  ulcer. — This  is  as  much  the  conse- 
quence as  the  cause  of  delay  in  healing.  It  is  mostly 
seen  in  varicose  ulcers  of  the  leg.  The  return  of 
blood  is  prevented  by  the  over-full  veins,  and  the  result 
is  that  the  granulations  are  deprived  of  their  proper 
supply  of  arterial  blood,  and  the  tension  in  them  is 
increased.  Moreover,  as  these  ulcers  are  situated  in 
the  front  of  the  leg,  they  are  liable  to  friction;  and  as 
but  little  areolar  tissue  intervenes  between  the  base 


2  8  Surgical  Pathology.  [Chap.  in. 

and  margin  of  the  ulcer  and  the  underlying  bone, 
adhesion  takes  place,  and  this  prevents  cicatrisation. 
The  margin  of  the  ulcer  is  thick  and  indurated,  almost 
cartilaginous  in  consistence.  It  may  be  more  than 
an  eighth  of  an  inch  deep.  It  usually  forms  a  steep 
declivity;  it  is  rarely  undermined.  Microscopical 
sections  of  the  walls  show  a  coarsely  fibrillated  or 
homogeneous  substance,  in  which  leucocytes  are  im- 
bedded. The  number  of  the  latter  varies  inversely 
as  the  induration.  The  granulations  at  the  base  are 
unhealthy;  they  may  be  large  and  cedematous,  or 
almost  wanting.  The  papillse  of  the  surrounding  skin 
are  hypertrophied ;  they  may  be  hidden  by  the 
exudation,  or  give  a  warty  appearance  to  the  surface. 
The  skin  itself  is  congested,  and  often  deeply  pigmented. 

Symptomatic  ulcers. 

1.  Varicose  ulcers. — No  other  variety  passes 
through  so  many  phases  of  the  ulcerative  process. 
They  are  of  great  interest  on  account  of  their  fre- 
quency, and  the  difficulty  that  attends  their  cure. 
AVe  class  them  with  the  symptomatic  ulcers,  since 
their  origin  or  extension  depends  upon  a  diseased 
state  of  the  veins.  They  are  almost  confined  to  the 
lower  extremity,  for  in  this  part  varix  of  the  cutaneous 
veins  reaches  its  highest  development;  and  besides 
this,  the  leg  is  much  exposed  to  injury,  the  skin  is  in 
close  proximity  to  the  bone,  and  therefore  liable  to 
become  adherent  to  it,  and  the  force  of  gravity  adds 
to  the  difficulty  of  the  venous  circulation. 

Mode  of  oi^igin. — Varicose  ulcers  begin  in  one 
of  four  ways  : — 

(1)  By  rupture  of  the  attenuated  walls  of  a  dilated 
vein. 

(2)  By  thrombosis  of  a  cutaneous  vein  and  its 
capillary  tributaries. 

Now  there  is  but  little  vascular  communication 
between  contiguous  capillary  areas  of  the  skin,   and 


Chap.  III.]  Ulceration.  29 

consequently  the  part,  cut  off  from  its  direct  supply, 
dies,  and  is  cast  off  as  a  slough,  or  it  undergoes  mole- 
cular softening.  In  either  case  a  circular  or  oval 
ulcer  is  left. 

(3)  By  an  abrasion. 

(4)  By  the  gradual  transition  of  eczema  to  ulceration. 
The  inflammation  for  a  time  causes  only  a  catarrhal 

exudation,  but  sooner  or  later  the  true  skin  is  exposed 
by  the  destruction  of  the  rete. 

If  on  the  first  appearance  of  a  varicose  ulcer  it  be 
kept  clean  and  protected  from  injury,  and  the  pressure 
in  the  veins  be  lessened  by  raising  the  limb,  it  will 
readily  heal.  On  the  other  hand,  the  deleterious  effect 
of  decomposing  discharge,  the  continual  fretting,  and 
the  congested  state  of  the  ulcer  and  skin  around, 
increase  and  perpetuate  the  impairment  of  nutrition. 
The  venous  distension  is  the  chief  cause  of  cedema  of 
the  granulations,  of  rupture  of  capillaries,  and  pig- 
mentation of  the  skin.  It  also  explains  the  failure  at 
cicatrisation,  for  whilst  it  prevents  healthy  granulation, 
it  gives  time  for  the  lymph  effused  into  the  base  and 
edge  of  the  ulcer  to  become  indurated,  and  so  to  act  as 
a  secondary  barrier  to  the  circulation. 

The  inflammation  that  extends  for  some  distance 
beyond  the  ulcer  causes  eczema  of  the  skin. 

Apart  from  the  general  treatment  applicable  to 
any  ulcer,  the  special  indication  is  to  support  the 
vessels  by  pressure  and  position,  and  thus  remove  the 
prime  cause  of  the  ulcer  spreading  or  remaining 
stationary. 

Of  the  remaining  symptomatic  ulcers,  some  are  due 
to  a  diathetic  state,  and  others  to  a  specific  poison. 
In  the  former  group  we  place  malignant,  lupous, 
and  scrofulous  ulcers ;  in  the  latter,  syphilitic, 
typhoid,  etc. 

2.  Malignant  ulcers.  —  {Vide  Encephaloid, 
scirrhous,  and  epithelial  cancer,  and  rodent  ulcer.) 


30  Surgical  Pathology.  [Chap.  iii. 

3.  L<iipo«s  ulcers. — {Vide  Lupus.) 

4.  Scrofulous  ulcers. — There  are  three  ways 
in  which  scrofula  is  connected  with  ulceration  :  (1)  It 
may  determine  and  modify  ulceration  of  the  skin 
affected  with  lupus  {vide  Lupus)  ;  (2)  it  may  cause 
it  through  the  medium  of  suppuration  in  lymphatic 
glands,  bone,  etc.  ;  (3)  it  may  cause  it  directly,  without 
any  other  predisposing  cause,  or  the  previous  existence 
of  disease  of  another  part. 

Sinuses,  resulting  from  caries  of  bone,  open  on  the 
surface  by  apertures,  which  appear  closed  by  the 
granulations.  The  latter  in  some  cases  are  fungous, 
and  the  mass  everted ;  but  quite  as  often  they  are 
small  and  pale.  In  the  latter  case  the  ulceration 
sometimes  spreads  to  a  considerable  distance,  and  has 
all  the  characters  of  a  strumous  sore.  The  same  may 
be  said  of  the  undermined  ulcers  of  the  neck  and 
other  parts  where  lymphatic  glands  have  suppurated. 
Not  uncommonly  the  inflammation  first  shows 
itself  as  an  eczema ;  but  as  a  rule  a  small  abscess, 
which  forms  in  the  subcutaneous  tissue,  opens  and 
leaves  an  ulcer  with  undermined  edges.  This  is  very 
frequent  over  bony  prominences,  and  other  parts 
liable  to  friction. 

Strumous  ulcers  are  very  chronic.  The  base  is 
smooth  and  dry,  or  bathed  with  an  ichorous  pus  secreted 
by  small  unhealthy  granulations.  The  edges  are  thin, 
and  often  widely  undermined.  The  skin  around  is  of 
a  dull  purple  colour,  from  congestion.  A  probe  may 
sometimes  be  passed  for  several  inches  beneath  it. 
These  ulcers  occasionally  spread  over  a  wide  surface, 
and  when  they  heal  leave  unstable  scars.  When 
situated  over  bones  and  tendons  {e.g.,  about  the  mal- 
leoli), their  bases  become  adherent  to  the  parts  be- 
neath, and  are  much  exposed  to  irritation  from 
movement  and  friction.  Healing  may  be  indefinitely 
delayed  in  such  cases,  and  when  it  does  take  place 


Chap.  III.]  Ulceration.  31 

the  part  is  coarsely  granular  from  hypertrophied 
papillae.     This  is  known  as  a  "warty  cicatrix." 

Specific  symptomatic  ulcers. — Specific  ulcers 
are  caused  by  the  action  of  a  virus  conveyed  by  con- 
tagion or  infection.  They  include  syphilis  and  the 
acute  specifics — typhoid,  etc. 

Syphilitic  ulcers. — These  may  be  divided  into 
primary,  secondary,  and  tertiary.  The  primary  sores 
or  chancres  are  of  two  kinds,  infective  and  non- 
infective,  indurated  and  soft.  The  latter  terms  are 
misleading  in  practice,  for  a  soft  sore  may  harden  by 
local  irritation  or  specific  induration  later  on.  A  hard 
sore  can  be  made  to  suppurate  and  spread  by  the 
irritation  of  decomposing  discharges  or  artificial 
stimulation. 

Nou-infective  ciiancres  are  often  multiple,  it 
may  be  from  the  first,  or  from  auto-inoculation.  They 
form  quickly,  within  a  few  days.  A  pustule  bursts 
and  leaves  a  small  painful  ulcer,  with  sharply  cut  edge 
and  purulent  base.  For  a  time  it  continues  to  spread, 
but  if  left  to  itself  runs  a  course  of  about  six  weeks. 
The  virus  contained  in  the  secretion  is  highly  irrita- 
tive. Conveyed  by  the  lymphatics  to  the  next  set  of 
glands,  it  excites  acute  inflammation,  which  is  very 
likely  to  end  in  suppuration  in  the  form  of  lymphatic 
or  peri-lymphatic  abscess. 

From  general  and  local  neglect  these  chancres 
occasionally  spread  extensively,  and  are  then  termed 
phagedsenic. 

Infective  cliancre.  —A  typical  hard  sore  shows 
only  an  abrasion  or  fissure.  The  induration  is  very 
marked  and  circumscribed.  A  thin  ichorous  discharge 
exudes  from  the  surface.  It  contains  large  clear  cells 
with  two  or  more  nuclei,  which  some  pathologists 
consider  characteristic.  We  cannot  confirm  this  view. 
The  induration  of  the  base  of  the  ulcer  is  a  sign  of 
constitutional  infection,  and  appears  from  seven  days 


32  Surgical  Pathology.  [Chap.  iii 

to  seven  weeks  after  inoculation  (Lee).  There  are 
induration  and  moderate  enlargement  of  the  nearest 
group  of  lymphatic  glands,  but  not,  as  a  rule,  suppura- 
tion. 

Between  characteristic  hard  and  soft  sores  there  is 
every  gradation,  whether  we  look  to  the  extent  of  the 
induration  and  ulceration,  or  the  nature  of  the 
discharge.      {Vide  Syphilis.) 

Secondary  sypliilitic  ulcers. — These  include 
mucous  tubercles  and  other  superficial  ulcers.  Mucous 
tubercles  are  typical  specimens  of  fungous  ulcers. 
They  are  met  with  at  the  junction  of  skin  with 
mucous  membrane,  especially  about  the  vulva  and 
anus.  They  are  also  found  on  the  mucous  membranes 
of  the  mouth,  pharynx,  and  larynx,  and  on  the  skin  ; 
e.g.,  in  the  flexure  of  the  groin,  in  those  parts,  in 
fact,  where  friction,  moisture,  and  acrid  discharge 
cause  irritation.  They  are  sessile  masses  of  granula- 
tions which  secrete  a  glairy  muco-pus.  They  differ 
from  piles  (1)  in  encroaching  more  upon  the  skin,  (2)  in 
their  being  pink,  and  not  bluish  in  colour,  (3)  in  being 
flatter.  The  mistake  most  likely  to  be  made  is  that 
of  confounding  mucous  tubercles,  seated  on  external 
piles,  with  simple  ulceration  of  the  latter. 

The  secondary  ulcers  ot  the  tliroat  and 
moutli  are  met  with  chiefly  on  the  tongue,  soft 
palate,  and  tonsils.  They  appear  at  first  as  milky- 
white  patches  of  epithelium  soddened  by  exudation. 
On  removal  of  the  epithelium,  superficial  ulcers  are 
left.  These  are  oval  or  roundish  in  outline.  They 
secrete  pus.  They  tend  to  get  well  of  themselves. 
They  are  for  the  most  part  symmetrical. 

Tertiary  sypliilitic  wlcers  commence  by  the 
breaking  down  of  gummata,  when  they  are  deep  and 
their  edges  undermined ;  or  by  a  more  superficial 
lesion  of  the  skin  and  mucous  membranes.  They  are 
less  symmetrical  than  the  early  secondary  ulcers,  and 


Chap.  III.]  Ulceration.  33 

are  less  likely  to  undergo  complete  spontaneous  cure. 
They  spread  in  a  serpiginous  manner,  extending  at 
the  margin,  whilst  they  heal  in  the  centre,  so  that 
wide  cicatrices  are  bordered  by  bands  of  ulceration. 

Hutchinson  says  that  "  syphilis  is  the  parent  of 
all  phaged^ena."  To  this  we  cannot  entirely  subscribe, 
believins:,  as  we  do,  that  there  are  other  causes  that 
may  produce  it  in  wounds  exposed  to  bad  hygienic 
conditions.  Phagedaena  is  a  true  ulceration.  The 
tissues  bounding  the  ulcer  rapidly  melt  away  as  the 
ulcer  spreads  ;  hence  it  is  chiefly  to  the  margin  that 
one's  attention  is  directed. 

A  sloug'tiiiig'  ulcer  is  a  combination  of  ulceration 
and  gangrene.  Visible  portions  of  tissue  die,  and 
remam  attached  for  some  time  to  the  base  of  the 
ulcer,  and  their  histological  characters  can  still  be 
recognised.     {Tide  Gangrene.) 

Primary  syphilitic  sores  are  occasionally  phage- 
dsenic,  both  at  the  point  of  inoculation  and  as  a  sequel 
of  lymphatic  bubo.  They  destroy  the  tissues  widely 
and  deeply,  including  vessels  such  as  the  arteria  dorsalis 
penis,  and  the  large  arteries  and  veins  in  the  groin. 

Tertiary  phagedsenic  ulceration  attacks  the  skin, 
throat,  nose,  and  rectum.  We  have  seen  it  spread 
over  the  greater  part  of  the  face  and  eat  away  the 
external  ear.  In  the  throat  and  rectum  it  may  give 
rise  to  dangerous  haemorrhage. 

Typlioid.  ulcers  afford  a  good  example  of  ex- 
tensive lesion,  with  but  little  cicatricial  contraction. 
This  is  due  to  the  rapidity  with  which  the  morbid 
process  subsides.  .  They  contrast  strongly  with  tuber- 
cular ulcers  of  the  intestine,  which  are  very  chronic, 
and  give  rise  to  a  puckering  and  narrowing  of  the  gut. 
Typhoid  ulcers  lie  in  the  axis  of  the  bowel,  tubercular 
athwart  it,  the  former  affecting  Peyer's  patches  and 
the  solitary  glands,  the  latter  following  the  course  of 
the  blood-vessels. 

D 


34  Surgical  Pathology.  [Chap.  iv. 

Typhoid  ulcers  are  sharply  defined,  and  their 
margin  is  often  shreddy  and  undermined.  Tubercular 
ulcers  have  an  indurated  base  and  edge. 


CHAPTEH  lY. 

GANGRENE. 

Gangrene,  or  death  of  a  visible  portion  of  tissue, 
ensues  whenever  the  circulation  is  arrested,  or  so  far 
impeded  that  the  vitality  cannot  be  maintained. 

The  dead  portion  is  termed  a  sphacelus,  or  slough, 
and,  in  the  case  of  bone,  a  sequestrum:  It  may 
depend  upon  one  primary  cause,  as  when  a  large 
artery  or  several  small  ones  are  blocked  by  fragments 
of  clot  detached  from  the  interior  of  an  aneurism. 
But  more  often  several  factors  are  combined  in  their 
action  ;  thus,  in  so-called  spontaneous  senile  gangrene, 
the  heart's  action,  perhaps,  is  weak  from  fatty  de- 
generation, the  large  arteries  roughened  by  athero- 
matous deposits,  the  medium  or  smaller-sized  ones  rigid 
and  irregular  from  calcification  of  the  middle  coat, 
the  capillaries  obstructed  by  the  pressure  of  some 
slight  accidental  inflammation,  whilst  the  circulation 
through  the  veins  may  be  impeded  by  varicosities,  or 
by  a  difficulty  in  the  blood  traversing  the  pulmonary 
capillaries  from  bronchitis  and  emphysema. 

Dry  and  moist  g'ang'rene. — The  terms  dry  and 
moist  as  applied  to  gangrene  are  only  relative,  serving 
as  types  for  the  clinical  grouping  of  cases  which  vary 
within  considerably  wide  limits.  The  more  the  ob- 
struction is  on  the  arterial  side  of  circulation,  the 
drier  will  the  necrosed  tissue  become ;  for  then,  whilst 
the  l^lood   enters  in   a  gradually-diminishing  stream, 


Chap.  IV.]  Gangrene.  35 

the  continual  evaporation  desiccates  the  tissues  until 
the  skin  is  "mummified,"  or  hard,  dry,  and  leathery; 
on  the  other  hand,  if  the  arterial  supply  be  free,  but 
the  transit  through  the  veins  and  capillaries  be 
checked,  the  tissues  are  gorged  with  blood  and 
soddened  by  exudation. 

Senile  gangreiae  sometimes  starts  from  diffuse 
thrombosis  of  the  tibial  arteries  and  their  branches. 
The  low  vitality  of  the  walls  of  the  vessels  favours 
coagulation  of  the  blood,  and  this  is  aided  by  the 
sluggishness  of  the  current  from  (1)  a  weak  propelling 
power,  (2)  the  resistance  due  to  increased  friction 
against  a  rough  surface,  and  (3)  loss  of  elasticity. 
The  coagulation,  moreover,  closes  the  circuits  of 
collateral  supply,  and  so  the  tissues  are  starved  from 
want  of  sufficient  nourishment.  The  force  transmitted 
through  the  arteries  no  longer  reaching  the  veins, 
stagnation,  followed  by  clotting,  supervenes  in  them 
and  the  capillaries  ;  and  so  the  whole  vascular  area 
becomes  occluded.  Such  is  the  pathology  of  those 
cases  of  gangrene  extending  slowly  over  a  wide  tract 
of  tissue. 

In  many  cases  the  onset  is  accidental,  some  slight 
injury  causing  inflammatory  thrombosis,  which  con- 
tinues to  spread  far  beyond  the  limits  of  the  original 
seat  of  irritation. 

The  arrest  of  the  gangrene  is  apt  to  occur  near  the 
joints,  where  the  arterial  supply  is  freer  than  else- 
where, and  the  anastomoses  larger  and  more  numerous. 

Ctiangfes  in  the  dead  tissues. — Evaporation 
goes  on  after  the  circulation  has  stopped,  and  so  a 
gradual  desiccation  reduces  the  part  to  a  dry  hard 
mass.  The  red  blood-corpuscles  break  up,  and  thus 
set  free  the  colouring  matter,  which  rapidly  diffuses 
itself,  and  becomes  reduced  in  the  general  disintegra- 
tion of  the  tissues,  so  that  it  appears  in  the  form  of 
black  granules  of  hsematin;  hence  the  dark  discolora- 


36  Surgical  Pathology.  [Chap.  iv. 

tion,  which  is  increased  by  the  iron  of  the  blood 
combining  with  sulphur  derived  from  the  decomposi- 
tion of  albuminoid  bodies. 

The  leucocytes  undergo  fatty  degeneration,  but 
they  persist  much  longer  than  the  red  corpuscles. 
Adipose  tissue  discharges  its  fat,  which  takes  the  place 
of  the  water  lost  by  evaporation,  acts  as  a  preservative 
to  the  structures  it  infiltrates,  and  gives  the  trans- 
lucent appearance  on  section. 

The  structural  identity  of  the  tissues  is  maintained 
for  a  long  time,  cartilage,  tendons,  ligaments,  and 
muscles  especially  resisting  the  chemical  changes  that 
tend  to  obliterate  their  characteristic  features.  The 
medulla  of  bone  perishes  like  other  unstable  matter, 
but  the  osseous  framework  remains  intact.  The 
fibres  of  striped  muscle  become  dissociated,  and  split 
transversely  into  their  sarcous  elements ;  pigment 
granules  are  seen  within  the  sarcolemma,  derived 
probably  from  the  colouring  matter  of  the  muscle. 
In  nerves,  the  white  substance  of  Schwann  breaks  up 
and  liquefies  j  the  primate  sheaths  collapse  around  the 
axis  cylinders,  which  are  the  last  to  go.  The  endo- 
thelial cells  of  the  blood-vessels  quickly  disappear ; 
next  the  muscular  fibres  and  the  adventitia ;  and 
finally  the  elastic  coat.  Crystals  of  stearic  acid,  choles- 
terine,  etc.,  are  formed  by  the  decompositions  of  fat  set 
free  from  the  corpuscles  or  derived  from  metamor- 
phosis of  the  tissues. 

Hovi^  the  necrosed  part  is  got  rid  of. — In 
the  living  tissue  on  the  confines  of  the  dead  a  layer 
of  highly  vascular  granulations  makes  its  appearance. 
It  is  seen  on  the  surface  as  a  red  line  of  demarcation. 
The  thrombi  in  the  vessels  and  the  products  of  de- 
composition of  the  dead  structures  act  as  irritants, 
and  set  up  a  limited  inflammation  which  ends  abruptly 
next  the  gangrenous  part,  but  fades  away  into  the 
healthy  tissues. 


Chap.  IV.]  Gangrene.  37 

The  softening  which  begins  in  this  structure  as  tlie 
consequence  of  serous  and  cellular  infiltration  is  con- 
tinued by  the  destructive  action  of  the  granulation 
tissue,  and  does  not  cease  until  the  solution  of  con- 
tinuity is  complete,  or,  in  other  words,  until  the  dead 
part  is  set  free  from  the  living. 

The  bones  and  muscles  are  less  liable  to  gangrene 
than  the  skin  and  subcutaneous  cellular  tissue,  for 
they  are  fed  more  directly  by  the  main  arteries  which 
lie  near  them.  The  threatened  stoppage  of  the 
circulation  is  checked  or  averted  by  the  high  blood- 
pressure  and  free  and  large  anastomoses.  This  is  the 
explanation  of  the  conical  or  "  sugar-loaf  "  stump  left 
after  the  necrosed  structures  have  been  thrown  off 
spontaneously. 

Moist  g-angrene. — The  caiises  of  moist  gangrene 
are  (1)  acute  inflammation  ;  (2)  obstruction  to 
the  venous  circulation,  as  when  a  large  vein  is 
wounded,  or  a  bandage  applied  too  tightly ;  (3)  plug- 
ging of  an  artery  which  has  few  or  no  anastomoses, 
e.g.,  the  middle  cerebral.  The  result  is  a  venous  reflux, 
and  a  stagnation  in  the  area  of  distribution  of  the 
artery ;  (4)  localised  occlusion  of  the  main  artery  of 
a  limb ;  as,  in  some  cases  of  ligature  for  the  cure  of 
aneurism,  the  blood  reaches  the  distal  portion  of  the 
limb  by  smaller  vessels,  which,  being  rigid  from 
disease,  cannot  enlarge  in  time  to  set  up  a  sufficiently 
free  circulation,  the  obstruction  is  so  great  that  there 
is  not  force  enough  to  drive  the  blood  through  the 
veins  and  capillaries  ;  (5)  widespread  primary  capil- 
lary thrombosis,  as  in  cancrum  oris. 

A  good  example  of  moist  gangrene  from  inflam- 
mation is  seen  in  phlegmonous  erysipelas,  in  which 
the  tension  is  so  great  that  the  capillary  circulation 
stops  from  pressure  without  and  thrombosis  within, 
hence  the  sloughing  of  the  skin  and  cellular  tissue. 
The   effect  is  probably  heightened    by  the  action  of 


38  Surgical  Pathology.  [Chap.  iv. 

living  organisms  wtiicli  intensify  the  irritation,  cause 
the  blood  to  coagulate,  and  favour  decomposition. 

Free  incisions  provide  a  drain  for  the  exudations, 
unload  the  engorged  vessels,  and  remove  the  resistance 
of  tense  fasciae. 

Gangrene  of  the  internal  organs  is  necessarily- 
moist,  for  evaporation  cannot  take  place.  If  at  the 
same  time  the  air  is  excluded,  as  in  large  infarctions 
of  the  spleen  and  brain,  progressive  molecular  soften- 
ing replaces  ordinary  putrefaction. 

When  the  dead  part  is  exposed  on  the  surface  of 
the  body,  or  in  the  respiratory  and  alimentary  tracts, 
there  is  decomposition  with  the  evolution  of  stinking 
gases.  In  moist  gangrene  (of  the  leg,  for  example) 
the  skin  is  cold,  and  purple  from  congestion  and 
stagnation ;  not  uniformly  so,  however,  for  there  are 
mottlings  from  dilatations  and  rupture  of  small  vessels, 
and  streaks  showing  the  course  of  the  superficial  veins. 
It  pits  on  pressure,  for  there  is  a  loss  of  elasticity, 
and  a  bogginess  from  serous  infiltration. 

Evaporation  does  not  suffice  to  carry  oft'  all  the 
fluid  that  exudes ;  hence  the  epidermis  is  raised  in 
the  form  of  bullae  which  contain  blood-stained  serum, 
and  later  on  the  gaseous  products  of  putrefaction. 
Soon  a  soft  emphysematous  crackling  can  be  felt,  dne 
to  the  interstitial  liberation  of  gases  too  copious  to  be 
held  in  solution.  The  discoloration  gets  more 
diffused,  for  the  blood-corpuscles  break  up  and  dis- 
charge their  pigment,  which  then  infiltrates  the  tissues. 
Again,  the  vessels  burst  from  softening  of  their  walls 
and  the  pressure  of  inflation.  The  purple  tint 
changes  to  green  and  black.  The  epidermis  peels  off 
in  soft  flakes,  the  skin  and  cellular  tissue  melt  away, 
exposing  tendons  and  fasciae,  and  these,  dissolving,  leave 
the  bones  bare  and  discoloured.  The  sequence  of 
events  above  described  is  usually  broken  by  removal 
of  the  limb  or  the  patient's  death.     It  is  very  difficult, 


Chap,  iv.j  Gangrene.  39 

often  impossible,  to  tell  where  the  gangi-ene  will 
stop,  or  whether  it  will  stop  at  all  if  left  to  itself, 
especially  when  it  follows  progressive  thrombosis  of 
the  main  artery  and  vein,  or  infective  inflammation. 
Considering  the  danger  of  septic  intoxication  and 
infection,  and  the  uncertainty  of  spontaneous  arrest, 
it  is  better,  in  most  cases,  to  operate  early  and  wide  of 
the  disease. 

Hoigpita,!  gangrene,  called  also  sloughing 
phagedsena,  is  a  disease  that  attacks  wounds.  The 
circumstances  known  as  "  bad  hygienic  conditions,'' 
which  favour  the  origin  and  propagation  of  germs, 
conduce  likewise  to  the  development  of  this  formid- 
able disease.  Nor  does  this  view  conflict  with  the 
opinion  that  individual  predisposition  of  the  patient 
has  much  to  do  with  the  etiology ;  and  hence  it  can 
be  understood  why  a  man  already  broken  down  by 
privation,  by  long  exposure  to  unsanitary  influences 
or  exhausting  disease  (such  as  tertiary  syphilis)  should 
fall  a  prey  to  this  disease  sooner  than  one  in  the 
bloom  of  health. 

The  active  cause,  no  doubt,  is  some  virus  introduced 
from  without ;  but  its  ravages  will  be  more  extensive 
and  fatal  when  it  meets  with  tissues  of  impaired 
vitality.  We  take  it,  then,  that  hospital  gangTene 
is  due  to  inoculation  of  a  wound,  old  or  recent,  with 
an  organism  capable  of  causing  rapid  death  of  granu- 
lations, and  in  succession  all  the  structures  around 
and  beneath  them.  The  general  system  becomes 
infected,  partly  by  the  original  poison,  and  partly  by 
the  products  of  disintegration  of  the  tissues.  Absorp- 
tion from  the  wound  goes  on  unchecked,  for  there 
is  no  barrier  of  granulations  to  prevent  it.  Although 
in  some  ways  it  resembles  diphtheria  of  wounds, 
pyaemia,  and  septicsemia,  it  is  probably  distinct  from 
them.  The  disease  is  sometimes  sporadic,  though 
not  uncommonly    it   is  epidemic.      It  is   much  rarer 


40  ScrRGiCAL  Pathology.  [Chap.  iv. 

than  it  used  to  be/  for  the  circumstances  that 
conduce  to  its  development  have  been  to  a  great 
extent  done  away  with.  They  are  overcrowding  of 
wards  and  camps  with  patients  suffering  from  un- 
healthy wounds,  want  of  sufficient  means  to  cleanse 
such  wounds,  bad  ventilation,  and  all  other  conditions 
that  make  up  "  hospitalism "  in  its  most  virulent 
form. 

Local  changes. — As  the  name,  sloughing  pha- 
gedsena  denotes,  there  is  gangrene,  with  true  ulcera- 
tion or  molecular  disintegration.  The  disease  is  said 
to  assume  two  forms,  the  "pulpy"  and  "ulcerative." 
This  j)robably  depends  upon  the  mode  and  rapidity 
of  destruction  of  the  tissues.  When  it  is  very  rapid, 
and  the  vessels  are  extensively  thrombosed,  consider- 
able portions  die  before  they  are  cast  off,  and,  whilst 
adherent,  they  form  soft  decomposing  sloughs.  If,  on 
the  other  hand,  the  margin  melts  away  as  the  disease 
extends,  we  have  the  ulcerative  form.  Between  the 
two  extremes  there  is  every  gradation. 

The  base  of  the  sore  is  either  smeared  over  with 
pus  and  the  debris  of  disintegrated  tissue,  or  it  is 
occupied  by  dirty  gray  flocculent  sloughs.  The  margiri 
is  sometimes  undermined  ;  it  is  always  steep.  The 
skin  in  the  immediate  proximity  has  a  dull  purplish 
hue,  for  here  the  stagnation  and  thrombosis  are 
extremely  marked.  Beyond  this  is  the  usual  inflamma- 
tory hypersemia,  fading  into  the  healthy  structures. 
The  outline  varies ;  it  may  be  of  indefinite  shape, 
but  very  often  it  is  curvilinear,  and  either  crescentic, 
circular,  or  trefoil-like.  As  far  as  local  signs  go,  they 
are  much  the  same  as  in  phagedsenic  venereal  sores. 

Cancrum  oris. — Cancrum  oris,  or  gangrenous 
stomatitis,  is,  in  the  majority  of  cases,  the  sequel 
of  an  exanthematous  fever — scarlatina,  measles,  and 
typhoid.  It  is  not  certain  whether  it  is  the  direct 
result  of  the  specific  poison  in  these  cases,  or  due  to 


Chap,  v.]  Fever.  41 

the  marasmic  condition  left  after  the  virulence  of  the 
latter  has  been  , expended.  It  sometimes  occurs  in 
weakly  children  as  an  idiopathic  aiFection,  and  it  may 
be  induced  by  prolonged  mercurialisation.  It  affects 
the  gums  and  cheeks,  and,  very  rarely,  the  jaws,  as  it 
continues  to  spread.  '  I  once  removed  a  large  portion 
of  the  maxilla  that  had  necrosed. 

In  female  children  the  genitals  may  be  attacked, 
and  this  form  is  said  to  be  highly  infective,  from  the 
presence  of  moving  organisms. 

In  some  instances  it  commences  as  a  capillary 
thrombosis  in  the  substance  of  the  cheek,  but  more 
often  as  an  ulceration  of  the  mucous  membrane, 
which  extends  widely  and  deeply  in  the  surrounding 
tissues. 

In  a  typical  case,  the  skin  in  the  centre  of  the  gan- 
grenous patch  is  converted  into  a  coal-black  eschar ; 
next  to  this  is  a  livid  purple  zone  in  which  the  blood 
has  coagulated  ;  then  comes  a  ring  of  deep  congestion, 
which  fades  away  into  the  healthy  tissue.  On  separa- 
tion of  the  slough  a  perforation  is  found  in  the 
cheek,  but,  as  a  rule,  the  patient  dies  before  this  is 
effected. 

The  ulcerative  form  is  more  often  recovered  from 
than  that  which  begins  as  a  primary  parenchymatous 
gangrene. 


CHAPTER   Y. 

FEVER. 


Feveti  is  marked  by  a  rise  in  the  general  body 
temperature,  and  disordered  function  of  the  various 
organs.  The  average  temperature  of  the  body  in 
health  is  98-4°  F.,  and  this  is  pretty  constant  under 


42  Surgical  Pathology.  [Chap. v. 

widely  different  external  conditions.  If  it  be  ex- 
ceeded by  one  degree,  the  patient  may  be  said  to  be 
feverish. 

Hxplanation  of  the  pyrexia. — Several  theories 
have  been  advanced  to  account  for  this,  but  it  may  be 
safely  said  that  each  is  too  exclusive.  We  will  take 
them  in  order : 

1.  ]>iimmis]ied  penspiration.  —  In  simple 
fever  the  skin  is  hot  and  dry,  which  means  that 
there  is  a  check  upon  the  cutaneous  perspiration,  or, 
in  other  words,  a  quantity  of  heat  that  should  be 
extracted  from  the  body  by  evaporation  from  its 
surface  is  retained.  This  of  itself  must  of  necessity 
tend  to  raise  the  temperature,  but  that  it  is  not  the 
sole  cause  is  proved  by  the  fact  of  a  patient  remain- 
ing feverish  throughout  prolonged  perspiration.  Thus, 
if  the  secretion  of  sweat  be  forced  by  pilocarpine 
during  the  hot  stage  of  malarial  fever,  the  tempera- 
ture continues  to  rise  for  some  time  afterwards.  This 
is  not  inconsistent  with  a  fall  of  temperature  during 
the  sweating  stage  of  this  disease,  and  after  the  rigors 
of  pyaemia.  By  a  physical  law,  rapid  evaporation 
must  get  rid  of  a  quantity  of  heat,  but  the  production 
meanwhile  may  be  greater  than  the  removal. 

2.  Increased,  production  of  lieat. — (a)  Some 
have  asserted  that,  at  the  seat  of  local  inflammation 
(say  an  acute  abscess),  the  heat  derived  from  increased 
destruction  of  tissue  raises  the  temperature  of  the 
part,  and  that  the  blood,  as  it  courses  through,  is 
made  hotter.  This,  too,  is  true  as  far  as  it  goes,  but 
then  there  is  no  constant  ratio  between  the  intensity 
of  the  local  inflammation  and  the  height  of  the 
general  fever.  A  mere  bead  of  pus  beneath  the  skin 
may  increase  the  body  heat  by  five  or  six  degrees. 

(b)  The  influence  of  the  nervous  system. — It 
is  well  known  that  there  is  a  heat-regulating  centre 
in  the  medulla  oblongata,  and  that  this  may  be  dis- 


Chap,  v.]  Fever.  43 

turbed  in  various  ways  :  {a)  through  the  cerebrum, 
as  the  result  of  emotional  excitement ;  (6)  reflexly, 
from  irritation  of  the  peripheral  nerves  ;  (c)  from  the 
action  of  pjrogenous  matter  absorbed  from  the  seat  of 
inflammation.  The  rise  of  temperature  from  cerebral 
excitement,  though  it  may  amount  to  several  degrees, 
is  very  transient.  Billroth  disbelieves  the  reflex  irri- 
tation theory.  He  says  that  if  a  wound  be  inflicted 
upon  the  foot  of  a  dog,  after  all  the  nerves  going  to 
the  limb  have  been  divided,  the  temperature  will  still 
rise  to  the  same  degree  as  if  the  nerves  had  been 
left  intact.  This  proves  nothing ;  for  the  nerves  can- 
not be  divided  without  causing  a  wound,  and  the 
inflammatory  products  from  this  must  be  in  contact 
with  the  central  end  of  the  nerve  ;  besides,  the  opera- 
tion itself  must  cause  considerable  irritation  of  the 
nerves.  Other  observers  have  shown  that  a  rise  in 
temperature  is  directly  connected  with  nerve  irrita- 
tion. At  a  focus  of  inflammation  the  irritation  may 
be  mechanical,  from  stretching  of  the  nerves,  or 
chemical,  from  the  action  of  the  inflammatory  pro- 
ducts. In  either  case  the  stimulus  is  conveyed  to 
the  centre  in  the  medulla,  and  there  transmitted  into 
a  fresh  stimulus,  which  is  sent  to  the  tissues  through- 
out the  body,  exciting  them  to  increased  combustion. 

(c)  The  action  of  infective  matter. — By  infec- 
tive matter  we  do  not  mean  the  products  of  pu- 
trescent decomposition  of  the  tissues  and  discharges 
of  a  wound,  but  merely  the  outcome  of  the  chemical 
changes  that  take  place  in  all  cases  of  inflammation. 
This  may  be  modified  by  decomposition,  or  the  pre- 
sence of  a  specific  poison,  circumstances  which  explain 
the  great  variety  of  fevers.  .  Absorption  goes  on 
through  the  capillaries  and  lymphatics,  and  thus  the 
blood  becomes  charged  with  poisonous  material,  which 
then  acts  upon  the  medulla,  and  possibly  on  the  other 
tissues  through  which  it  circulates. 


44  Surgical  Pathology.  [Chap. v. 

Other  sig^iis  of  fever. — All  the  tissues  of  the 
body  suffer  more  or  less.  This  is  shown  by  disordered 
function,  and  markedly  in  the  secretory  organs.  The 
work  done  by  them  is  much  diminished.  The  blood 
is  charged  with  noxious  matter  in  a  threefold  way  : — 
there  is  the  morbid  material  furnished  by  the  local 
inflammation ;  to  this  is  added  the  results  of  a  general 
increase  in  the  oxidation  of  the  tissues,  and  the  nega- 
tive effect  of  partial  arrest  of  secretion  and  excretion. 
Though  many  of  the  symptoms  are  in  part  due  to  the 
direct  action  of  the  pyrogenous  matter  on  the  organs 
which  fail  to  carry  out  their  functions,  much  is 
explained  by  the  disturbed  state  of  the  vaso-motor, 
secretory,  and  trophic  nerves  of  the  glands.  The  first 
of  these  explains,  to  a  great  extent,  the  diminution  in 
the  watery  constituents ;  for,  the  lower  the  pressure, 
the  less  the  filtration ;  the  second,  perversion  of  the 
special  function  of  the  secreting  cells  ;  and  the  third, 
disorderly  metabolism  of  the  tissue  elements. 

The  urine  is  high-coloured,  of  high  sp.  gr. ;  it 
deposits  urates.  The  water  is  scanty ;  urea  and  uric 
acid  are  increased.  The  chlorides  are  diminished ;  in 
acute  pneumonia  they  are  often  absent.  In  simple 
fever  the  perspiration  is  diminished  ;  it  is  very  acid, 
notably  so  in  rheumatic  fever.  In  this  disease,  and  in 
hectic  fever  and  pysemia,  profuse  sweating  is  a  pro- 
minent symptom.  The  secretion  of  saliva  is  checked, 
and  the  discharge  from  the  mucous  glands  is  more 
tenacious  than  natural ;  hence  the  clamminess  and 
thirst.  There  is  more  or  less  anorexia,  perhaps 
vomiting.  The  furred  condition  of  the  tongue  is  an 
index  to  the  state  of  the  stomach.  Constipation  is 
the  rule ;  but,  in  certain  fevers  that  have  a  specific 
effect  on  the  intestines  ie.g.^  cholera,  typhoid,  and 
some  cases  of  septicaemia)  there  is  diarrhoea.  Whether 
there  be  flux  or  drought  depends  upon  the  vascular 
tension,  the  condition  of  the  walls  of  the  vessels,  and 


Chap,  v.]  Fever.  45 

the  chemical  and  physical  nature  of  the  fluids  that 
dialyse. 

The  nervous  system. — There  are  symptoms  directly 
referable  to  the  nervous  system,  such  as  headache 
and  delirhtm.  These  are  explained  rather  by  the 
pyrexia  and  toxic  influence  upon  the  brain  than  by 
the  extent  of  vascular  congestion ;  and  hence  the 
futility  of  excessive  depletion  by  blood-letting.  Such 
treatment  might  do  actual  harm  by  adding  the  effects 
of  anaemia  to  those  of  the  fever.  Sir  W.  Jenner  has 
shown  that  in  the  specific  fevers,  and  particularly  in 
typhoid,  headache  ceases  with  the  onset  of  delirium, 
whereas  in  tubercular  meningitis  it  persists.  The 
explanation  is  this  :  the  poison  of  the  specific  fever 
at  first  excites  the  nervous  system,  and  one  of  the 
chief  signs  of  this  is  headache  j  but,  later,  it  deadens 
the  perceptive  centres,  and  gives  full  play  to  disorderly 
and  uncontrollable  discharge  of  nerve  energy — deli- 
rium. In  tubercular  meningitis  the  cause  of  the 
headache  is  twofold ;  there  is  the  pyrexia,  and  the 
irritation  of  the  brain  by  local  inflammation.  The 
latter  is  so  intense  that  it  is  only  when  the  exhaustion 
from  the  fever  and  subsequent  compression  has  super- 
vened that  the  headache  is  abolished.  The  ph^^sical 
conditions  of  headache  are  constant  throughout  the 
course  of  the  two  diseases ;  but  by  the  time  the 
toxaemia  of  the  specific  fever  has  caused  delirium,  it 
has  masked  the  headache. 

The  musGidar  system. — There  is  increased  activity 
at  the  expense  of  diminished  power.  In  slight 
cases  this  may  not  be  evident  during  rest,  but  it 
becomes  manifest  on  exertion  ;  there  is  the  sense  and 
sign  of  weakness  in  the  tremulous  state  of  the  patient. 
This  is  mainly  nervous,  but  the  state  of  the  muscular 
fibres  themselves  (for  pyrexia  causes  fatty  degeiiera- 
tion)  has  some  share  in  the  process.  When  the  fever 
is  high  or  the  toxaemia  intense,  and,  above  all,  when 


46  Surgical  Pathology.  ■    [Chap. v. 

the  blood  is  suddenly  charged  with  infective  matter, 
the  natural  tonic  contraction  of  the  muscles  is  replaced 
by  a  succession  of  rapidly  repeated  contractions,  over 
which  the  patient  has  little  or  no  control.  There  are 
four  degrees  of  this  : 

1.  Fibrillar  tremor. — This  can  be  better  felt 
than  seen;  like  the  subsultus  tendinum,  it  indicates 
extreme  nervous  exhaustion. 

2.  Rigor. — Here  the  contraction  is  more  pro- 
nounced and  more  general.  It  is  accompanied  by  a 
sensation  of  cold  which  is  subjective,  for  before 
the  rigor  sets  in  the  temperature  has  generally  risen 
several  degrees.  It  is  the  relative  coldness  of  the 
atmosphere  to  the  heat  of  the  patient's  body,  which  in 
his  febrile  state  is  a  highly  sensitive  thermometer. 
The  mind  remains  clear,  firstly  because  the  disturbance 
is  mainly  confined  to  the  motor  centres,  and  secondly 
because  the  contractions  are  not  sufficiently  vigorous 
and  sustained  to  fix  the  chest  walls,  and  so  cause 
cerebral  congestion  from  asphyxia.  There  may  be 
only  an  initial  rigor ;  or  a  succession  of  rigors.  They 
vary  in  degree  from  chattering  of  the  teeth  to  shaking 
of  the  whole  body.  They  are  usually  followed  by 
profuse  perspiration,  not  alone  as  a  consequence  of  the 
rigors,  but  as  a  later  link  in  the  chain  of  toxic  effects. 

3.  Eclamptic  convulsions.  - — These  in  children  take 
the  place  of  rigors  in  the  adult,  for  in  them  there 
is  greater  excitability  of  the  nerve  centres.  Not  that 
adults  are  exempt  from  convulsions  as  the  result  of 
high  fever.  Primary  convulsions  usually  usher  in 
some  acute  fever,  pneumonia ;  e.g.,  when  they  occur 
later  some  grave  lesion  should  be  suspected — cerebral 
embolism,  thrombosis,  etc.  The  contractions  are  more 
violent  than  in  rigors.  There  is  loss  of  consciousness 
and  more  or  less  asphyxia.  There  are  many  causes 
of  convulsions,  but  here  we  are  only  considering  those 
dependent  upon  the  pyrexial  state. 


Chap. VI.]    Surgical  or   Traumatic  Fever.  47 

4.  Tetanic  or  tonic  spasm. — In  reality  it  is  clonic, 
but  the  contractions  are  so  minute  and  follow 
one  another  so  rapidly  that  without  the  aid  of  the 
myograph  they  appear  fused.  In  a  minor  degree  it  is 
seen  in  "cramp"  and  "stiffness,"  but  it  is  the  sympto- 
matic essence  of  two  pyrexial  diseases,  tetanus  and 
hydrophobia.  It  probably  depends  upon  a  more  con- 
tinuous irritation  than  either  a  rigor  or  "  clonic 
spasm."  The  discharge  of  nerve  energy  is  not  so 
violent  as  in  ordinary  convulsions,  and  therefore  the 
nerve  cells  are  not  so  quickly  exhausted. 


CHAPTER   YI. 

SIMPLE   SURGICAL    OR   TRAUMATIC   FEVER. 

After  an  operation  of  any  magnitude,  e.g.,  an  ampu- 
tation of  the  leg,  or  removal  of  a  breast,  the  patient 
becomes  feverish.  Eor  some  little  time  subsequent  to 
the  infliction  of  the  wound,  the  temperature  of  the 
body  is  generally  lowered.  This  is  due  to  the  shock 
of  the  injury  and  the  depressing  effects  of  the 
ansesthetic.  After  an  apyrexial  interval,  varying  in 
uncomplicated  cases  from  twelve  to  thirty-six  hours, 
the  usual  signs  of  fever  show  themselves ;  the  heat  of 
the  body  is  increased  ;  the  patient  looks  somewhat 
flushed ;  he  complains  of  feeling  hot  and  thirsty ;  his 
appetite  is  indifferent,  and  his  tongue  moist  and 
furred.  In  addition  there  are  headache  and  general 
restlessness. 

The  pyrexia  varies  within  a  range  of  three  or  four 
degrees;  the  temperature  is  rarely  below  100°  Fahr.  or 
above  102-5°. 

If  we  now  examine  the  wound  we  shall  find  very 


48  Surgical  Pathology.  [Chap.  vi. 

much,  as  follows  :  a  certain  amount  of  hypersemia, 
incidental  to  the  injury.  Tlie  surfaces,  which  become 
glazed  after  the  cessation  of  the  bleeding,  now  look 
moist  from  effusion  of  liquor  sanguinis  from  the  dilated 
vessels.  There  are,  in  fact,  the  signs  of  traumatic 
inflammation,  and,  other  things  being  equal,  the  height 
of  the  fever  is  proportionate  to  the  extent  of  the 
local  disturbance. 

Cause  of  the  fever. — Allowing  for  the  check 
on  the  cutaneous  perspiration,  and  the  possible  effects 
of  nerve  irritation  in  the  wound,  there  can  be  no  doubt 
but  that  the  general  symptoms  (the  fever)  depend 
mainly  upon  something  absorbed  from  the  wound  : 
(1)  Because  whatever  prevents  a  free  escape  of  discharge 
causes  an  accession  to  the  fever,  and  this  in  two  ways; 
it  affords  a  favourable  condition  for  putrefaction,  and 
increases  the  liability  to  absorption  of  the  decomposed 
products.  Per  contra,  the  temperature  falls  on  estab- 
lishing efficient  drainage ;  (2)  because  the  measures 
taken  for  keeping  a  wound  aseptic  minimise  the  height 
of  the  fever  curves.  *The  latter  proves  something 
more,  viz.,  that  the  so-called  traumatic  fever  is  to  a 
great  extent  a  state  of  septic  intoxication.  We  do 
not  say  entirely,  for  the  chemical  products  of  inflam- 
mation are  themselves  pyrogenous ;  as  witness  the 
j^yrexia  from  a  simple  subcutaneous  phlegmon.  In 
all  wounds  the  injury  destroys  the  vitality  of  a  certain 
amount  of  tissue,  and  the  necrosed  structures  are 
resolved  into  simpler  compounds.  In  open  and  exposed 
wounds  these  compounds  further  decompose,  and 
furnish  secondary  products,  which  on  being  absorbed 
induce  fever. 

The  coiKlitioii  of  tlie  wound  favours  absorp- 
tion, for  there  are  a  large  number  of  blood-vessels 
and  lymphatics,  which  take  up  fluids  from  the  surface 
and  transmit  them  to  the  blood  and  lymph  streams 
beyond.     As  these  vessels  become  firmly  occluded,  by 


Chap.  VI.]    Surgical  or   Traumatic  Fever.  49 

consolidation  of  the  clots  within  and  compression  of 
the  inflammatory  exudation  without,  the  fever  declines, 
even  whilst  the  wound  is  bathed  with  "  discharges." 
A  well-formed  layer  of  granulations  is  a  strong  pro- 
tection against  absorption,  for  the  direction  of  the 
osmotic  current  is  away  from  the  blood-vessels,  .and 
granulations  have  no  lymphatics. 

Traumatic  fever  is  generally  more  severe  when  it 
follows  operations  upon  tissues  indurated  by  chronic 
inflammation,  for  the  vessels,  being  imbedded  in  dense 
exudation,  cannot  collapse.  To  return  to  the  course  of 
the  fever.  In  ordinary  circumstances  it  subsides  in 
a  few  days,  it  rarely  lasts  beyond  a  week ;  if  so,  we 
begin  to  suspect  there  is  something  wrong  with  the 
wound,  and  to  fear  that  the  simple  traumatic  fever 
may  pass  into  the  graver  forms  of  blood-poisoning. 
It  rises  somewhat  sharply  at  the  beginning;  for  a  day 
or  two  it  oscillates  about  the  maximum,  with  slight 
morning  remissions.  It  terminates  by  lysis,  or  more 
rarely  by  crisis. 

In  some  cases  it  is  so  slight  that  its  existence  is 
only  revealed  by  the  thermometer.  When  a  large 
wound  unites  by  the  first  intention  fever  may  be 
entirely  absent;  hence,  as  Billroth  observes,  it  may  be 
considered  as  a  "pathological  accident,"  but  an  accident 
so  common  as  scarcely  to  deserve  the  name.  We 
would  once  more  repeat  that  it  is  the  result  of  local 
inflammation  and  absorption  of  decomposing  secretions 
and  tissues.  The  latter  may  justly  be  considered  as 
"an  accident,"  for  the  presence  of  a  slough  on  the 
surface  of  an  aseptic  wound  neither  excites  local 
inflammation  nor  causes  fever.  Billroth  distinguishes 
two  forms  or  stages  of  surgical  fever  :  (1)  That  due  to 
absorption  of  the  products  of  decomposition  of  necrosed 
tissues  on  the  surface  of  the  wound — primary  wound 
fever  ;  (2)  secondary  suppurative  fever,  which  depends 
on  the  taking  up  by  the  lymphatics  of  inflammatory 


50        "  Surgical  Pathology.  [Chap.  vii. 

products — pus.  He  says  that  primary  traumatic  fever 
may  go  on  to  septicsemia,  and  secondary  suppurative 
fever  to  pyaemia.  We  have  not  attempted  to  separate 
traumatic  from  inflammatory  or  suppurative  fever, 
for  in  practice  they  overlap. 


CHAPTER  YII. 

SEPTICEMIA   AND    PYEMIA. 

On  attempting  to  define  what  is  meant  by  the  terms 
septicsemia  and  pyaemia  one  is  met  with  this  difficulty, 
that  pathologists  are  by  no  means  agreed  as  to  the 
distinctive  characters  and  relationships  of  the  two 
conditions.  ^ 

Some  authorities  make  the  word  pyaemia  cover  all 
the  cases  of  septic  absorj)tion  from  wounds  or  inflam- 
matory foci  that  furnish  products  of  decomposition, 
whether  such  absorption  results  in  a  general  blood- 
poisoning  with  the  occurrence  of  secondary  metastatic 
infarctions  and  abscesses,  or  without  them.  They  say 
that  the  variations  observed  in  the  symptoms,  and 
post-mortem  signs,  depend  upon  the  virulence  or 
intensity  of  the  poison,  the  state  of  nutrition  of  the 
tissues,  and  certain  accidental  circumstances  likely  to 
modify  the  course  of  the  disease,  rather  than  upon  any 
specific  character  of  the  poison  in  different  instances. 
Thus  the  absence  of  secondary  metastatic  lesions  is 
explained  by  supposing  that  death  or  recovery  occurs 
before  sufficient  time  has  elapsed  for  their  develop- 
ment. We  cannot  admit  this  explanation,  because,  on 
the  one  hand,  multiple  secondary  abscesses  sometimes 

*  The  different  views  are  set  forth  with  great  clearness  in  the 
Transactions  of  the  Pathological  Society,  vol,  xxx.,  pp.  8—10. 


Chap.  VII.]       Septicemia  and  Pyemia.  51 

form  very  quickly  after  the  injury  or  inflammation, 
e.g.,  the  lungs  may  be  full  of  them  within  a  week  of 
the  onset  of  "  acute  necrosis";  and^  on  the  other,  un- 
complicated fatal  cases  of  septic  poisoning  are  occa- 
sionally of  much  longer  duration.  Billroth  considers 
that  the  two  afi'ections  are  quite  distinct,  though  they 
may  exist  together  (septopysemia).  He  regards 
septicaemia  as  a  severe  form  of  primary  traumatic 
fever,  due  to  the  putrefactive  decomposition  of  necrosed 
tissue  and  exudation,  prior  to  or  after  the  occurrence 
of  suppuration  ;  and  pysemia  as  essentially  dependent 
on  absorption  of  pus  :  "  reabsorption  of  pus  is  the 
cause  ;  intermittent  course  of  the  fever,  with  rapidly 
increasing  marasmus,  the  chief  symptom  ;  and  the 
metastatic  inflammations  very  essential  anatomical 
conditions." 

Dr.  Burdon  Sanderson  looks  upon  septicaemia  as  a 
non-infective  process,  or  one  in  which  there  is  no 
multiplication  of  the  poison  in  the  system.  Since  the 
poison  necessarily  becomes  greatly  diluted  in  the  blood 
and  tissues,  successive  inoculations  or  injections  from 
animal  to  animal  produce  less  and  less  eflfect,  or  they 
may  fail  altogether.  In  any  individual  case  the  result 
depends  (1)  upon  the  power  of  resistance  to  the  action 
of  the  septic  material ;  some  animals  are  more  suscep- 
tible than  others,  and,  ceteris  'paribus,  the  smaller  the 
animal  the  smaller  will  be  the  dose  necessary  to  kill 
it ;  (2)  upon  the  strength  of  the  dose ;  and  (3)  whether 
it  be  repeated  or  not. 

The  tendency  is  to  recovery,  but  the  animal  may 
be  so  overpowered  as  to  succumb  before  the  poison 
can  be  got  rid  of.  The  materies  morbi  consists 
of  the  chemical  products  of  decomposition  of 
organic  matter.  It  is  obviously  such  as  would  be 
furnished  by  a  large  wound  {e.g.,  the  placental  surface 
of  the  uterus),  and  probably  some  of  the  cases  of 
puerperal  fever  are  of  this  nature.      But   if  we  thus 


52  Surgical  Pathology.  [Chap.  vii. 

limit  the  application  of  the  term  septicaemia,  a  large 
number  of  cases  will  be  excluded,  in  whicli  there  is 
general  blood-poisoning,  also  without  secondary 
metastatic  abscesses.  It  has  been  proposed  to  de- 
signate these  by  the  term  "  septic  infection^''  in  con- 
tradistinction to  "  se'ptic  intoxication  "  applied  to  the 
former  group. 

In  septic  infection  all  the  signs  and  symptoms  of 
septic  intoxication,  or  simple  septic  poisoning,  may 
be  present ;  but  there  is  this  very  important  difference, 
that  in  the  former  the  poison  is  multiplied  in  the 
system  to  an  indefinite  extent,  and  the  disease  can  be 
communicated  from  animal  to  animal  without  any 
diminution  in  its  virulence,  in  fact  its  intensity  is  often 
increased  thereby.  This  is  the  nature  of  many  cases 
met  with  in  practice,  and  notably  in  post-parturient 
women. 

The  ease  with  which  puerperal  fever  can  be  in- 
duced by  infinitesimal  quantities  of  the  infecting 
material  is  too  well  known. 

If  we  conclude,  with  Billroth,  that  Jt9^/cem^a  is  essen- 
tially due  to  reabsorption  of  pus — decomposed,  thin, 
and  ichorous  pus  (for  a  considerable  quantity  of  freshly 
secreted  healthy  pus  may  be  injected  into  the  veins 
without  causing  any  serious  local  or  general  conse- 
quences)— purulent  infection,  as  it  is  called,  we  must 
also  conclude  that  there  are  three  distinct  forms  of 
blood-poisoning  :  (1)  Septic  intoxication  (without 
metastases)  from  the  absorption  of  the  chemical  pro- 
ducts of  decomposition  of  tissues  and  fluids,  products 
incapable  of  undergoing  multiplication  in  the  system, 
and  therefore  of  being  transmitted  from  animal  to 
animal  with  unimpaired  virulence ;  (2)  septic  infec- 
tion (without  metastases),  in  which  the  poison  is  hot 
only  multiplied,  but  to  a  certain  extent  developed 
in  intensity  as  it  passes  from  one  field  of  culti- 
vation  to    another;    (3)  pyaemia    or  septic   infection 


Chap.  VII.]       Septicemia-  AND  Pyemia.  53 

with  metastases  derived  from  one  peculiar  source — 
pus. 

But  we  are  at  a  loss  to  understand  what  there  can 
be  in  pus — which  is  only  "  fluid,  as  it  were,  melted, 
dissolved  inflammatory  new  formation"  (Billroth) — 
that  it  should  furnish  material  for  infection,  of  an 
altogether  specific  character. 

Simple  septic,  non-infective  intoxication,  or  the 
septicaemia  of  Dr.  Sanderson,  explains  most  of  the 
cases  of  severe  blood-poisoning  that  recover  without 
the  formation  of  secondary  abscesses.  But  it  does  not 
follow  that  all  cases  are  of  this  nature  ;  nor,  judging 
from  the  analogy  between  septic  infection  and  malig- 
nant pustule,  which  is  an  essentially  infective  disease, 
and  yet  fatal  in  only  about  one-third  of  the  subjects 
attacked  (Greenfield),  does  it  seem  improbable  that  a 
certain  number  of  patients  may  survive  the  death  of 
the  micro-organisms,  or  ferments,  or  whatever  the 
cause  of  infection  may  be,  providing  that  whilst 
active  these  agents  do  not  give  rise  to  widespread  or 
deep-seated  metastases. 

The  nature  of  the  poison.  —  The  immediate 
cause  of  the  blood-poisoning  seems  to  be  due  to  the 
unorganised  products  of  decomposition,  and  not  to  the 
organisms  that  determine  the  decomposition ;  for  the 
virulence  of  a  fluid  known  to  be  intensely  septic  is  not 
lessened  by  destruction  of  the  organisms  (Ander). 

Several  observers  have  shown  that  an  amorphous 
substance  can  be  extracted  from  the  fluid  that  causes 
septic  intoxication.  Bergmann  believed  its  composi- 
tion to  be  definite^  and  he  named  it  "  sepsin  "  accord- 
ingly. Billroth  doubts  its  specific  nature,  and  thinks 
that  there  may  be  several  products  of  decomposition 
capable  of  causing  the  symptoms. 

What  is  the  cause  of  septic  decomposition  1  Is 
the  agency  of  living  microscopical  bodies  essential  to 
the  process  1  probably  so,  for  in  all  decomposing  animal 


54  Surgical  Pathology.  [Chap. vii. 

fluids  they  are  there  in  abundance,  and  Dr.  Sanderson 
has  shown  that  the  products  of  decoroYJOsition  capable 
of  inducing  septic  intoxication  are  only  formed  in 
their  presence. 

What,  then,  is  the  reason  of  simple  septic  intoxica- 
tion occurring  in  one  instance,  and  septic  infection  in 
another  %  This  is  not  clear.  It  may  be  that  the 
organisms  that  set  up  ordinary  putrefaction  are  de- 
stroyed by  the  liAdng  tissues,  whilst  those  which  cause 
septic  infection  have  a  much  greater  power  of  resis- 
tance. This  would  of  course  imply  that  there  is  a 
specific  "  germ  "  in  each  case,  or  that  the  circumstances 
under  which  any  one  form  develops  vary  in  difierent 
instances.  From  the  intrinsic  difficulty  attending  the 
necessary  observations,  and  the  small  size  of  the 
organisms,  and  the  number  of  transitional  forms,  it  is 
not  surprising  that  the  results  obtained  should  in 
many  cases  be  directly  opposite. 

Por  the  most  part  these  organisms  conform  to  one 
of  two  types,  rod-shaped,  single  or  pointed  bacteria, 
possessed  of  a  vibratory  onward  movement ;  and 
micrococci  consisting  of  mere  rounded,  specks  of  pro- 
toplasm, isolated,  or  linked  to  form  strings  or  clumps, 
and  quiescent,  or  capable  only  of  oscillation,  which  is 
difficult  to  distinguish  from  the  Brownian  movement, 
common  to  all  minute  particles  suspended  in  fluids. 

But  these  characters  are  scarcely  sufficient  to 
determine  their  individuality;  still,  judging  from  what 
we  know  of  the  bacillus  of  malignant  pustule,  we 
cannot  deny  the  existence  of  specific  germs  in  the 
difierent  forms  of  septicaemia,  although  we  are  far 
from  understanding  their  modes  of  life  and  action. 

W.  Cheyne  concludes  from  his  observations  {vide 
Trans.  Path.  Soc,  vol.  xxx.,  p.  557,  et  seq.)  :  (1) 
That  the  micrococci  are  comparatively  harmless,  and 
that  they  are  quickly  destroyed  by  the  tissues  when 
they  gain  access  to  the  organism  ;   and  (2)  that  it  is 


Chap.  VII.]       Septicemia  and  Pyemia.  55 

the  bacterial  form  that  is  so  potent  in  causing  putre- 
faction and  septic  infection.  On  the  other  hand,  in 
the  report  on  "  Septicsemia "  contained  in  the  same 
volume,  pp.  50,  51,  it  is  stated  with  regard  to  pyae- 
mia that  micrococci  were  observed  "in  a  large 
number  of  cases  "  in  all  or  some  of  many  organs,  and 
that  "  bacteria  were  found  in  three  cases." 

Koch  asserts  that  "  organisms  are  not  found  in  the 
blood  of  animals  suffering  from  septic  intoxication," 
but  that  they  are  invariably  present  in  septic  infection. 
Billroth,  who  does  not  seem  to  draw  a  clear  distinction 
between  the  two  processes,  denies  that  their  presence 
is  necessary.  When  speaking  of  pyaemia,  which  is 
an  infective  disease,  he  says,  "  I  can  entirely  agree 
to  the  miasmatic  origin  of  pysemia,  if  by  miasm  is 

understood  what  I  understand  by   it , 

namely,  dust-like,  dried  constituents  of  pus,  and 
possibly  also  accompanying  minute,  living,  very  small 
organisms.' 

Is  putrefaction  necessary  to  blood  -  poisoning  ? 
Certainly  not,  if  the  evolution  of  stinking  gases 
be  taken  as  the  indication  and  measure  of  it,  as 
the  following  case  shows  :  Mr.  J.  Lane  amputated  a 
thigh  for  disease  of  the  knee-joint  with  all  antiseptic 
precautions.  The  discharges  remained  aseptic  and 
the  flaps  to  all  appearance  healthy,  and  post  mortem 
no  offensive  smell  could  be  detected  in  or  about  the 
wound.  The  symptoms  were  those  of  deep  septic 
intoxication.  Cadaveric  decomposition  set  in  early, 
and  was  very  rapid.  There  were  no  metastases. 
The  blood  and  discharges  were  not  examined  micro- 
scopically. 

Nor  need  the  local  irritation  caused  by  the  poison 
manifest  itself  in  destructive  inflammation,  although 
the  infection  may  cause  secondary  circumscribed  and 
diffuse  abscesses.  The  writer  once  lost  a  case  of 
lithotomy,   in  which  post  mortem  the  wound  in  the 


56  Surgical  Pathology.  [chap.  vii. 

bladder,  which  had  nearly  healed,  appeared  quite 
healthy.  There  were  no  signs  of  cystitis,  peritonitis, 
or  pelvic  cellulitis,  or  thrombosis  of  the  local  veins. 
The  lungs  were  riddled  with  small  abscesses,  and 
there  was  a  tract  of  diffuse  suppuration  between  the 
scajjular  muscles  in  the  back. 

Yet  although  putrefaction,  in  the  ordinary  accep- 
tation of  the  term,  is  not  a  necessary  condition  in  all 
cases,  it  is  so  exceedingly  common  that  it  is  safe 
to  infer  that  the  circumstances  likely  to  give  rise 
to  it  are  much  the  same  as  those  which  underlie  the 
occurrence  of  blood-poisoning,  whatever  form  the 
latter  may  take  ;  whether  it  be  simple  intoxication,  or 
intoxication  with  infection,  or  infection  with  metas- 
tases (pysemia),  or  one  or  other  combination  of  these 
phenomena. 

Excluding  the  theory  of  spontaneous  generation, 
and  admitting  that  the  organisms  found  in  the  dis- 
charges from  wounds  and  in  closed  inflammatory  foci 
are  the  cause  and  not  the  consequence  of  the  de- 
compositions attended  with  the  formation  of  septic 
matter,  and  also  that  they  are  introduced  from  with- 
out, we  can  understand  why  blood-poisoning  should 
be  so  closely  associated  with  the  overcrowding  of 
wards,  and  the  neglect  of  measures  calculated  to  keep 
a  wound  healthy. 

The  part  played  l>y  tlie  tissues.  —  This  is 
very  important,  both  as  regards  the  wound  and  the 
body  generally.  The  greater  the  bruising  and  lacera- 
tion, the  more  likely  is  a  patient  to  suffer  from  primary 
traumatic  fever,  and  its  more  severe  form,  septicaemia. 
There  are  several  factors  that  work  to  this  end  :  (1) 
A  considerable  portion  of  tissue  being  killed  outright, 
it  quickly  undergoes  putrefaction  if  germ-laden  air  be 
allowed  access  to  it;  (2)  a  large  number  of  blood- 
vessels and  lymphatics  are  opened,  and  thus  an  ex- 
tensive tract  for  absorption  is  provided ;    (3)  short  of 


Chap.  VII.]       Septicemia  and  Pyemia.  57 

actual  death,  the  vitality  of  the  tissues  about  the 
wound  is  greatly  impaired  by  the  injury  itself  and  the 
inflammation  it  sets  up. 

Dr.  Sanderson  has  shown  that  bacteria  "are 
incapable  of  producing  the  poison  of  septicaemia" 
(septic  intoxication)  "  in  the  healthy  organism." 
From  this  statement  we  must  not  infer  that  they 
do  not  gain  admission  to  the  body  by  the  wound 
or  some  of  the  natural  passages,  but  that  the  tissue 
elements  destroy  them,  or  are  at  least  able  to  resist 
their  action.  Yirchow  long  since  observed  that  the 
animal  tissues  tend  to  get  rid  of  matters  obnoxious 
to  them.  What  is  called  susceptibility  or  predis- 
position of  the  tissues  to  be  affected  by  specific  poisons 
(e.^.,  those  of  the  exanthematous  fevers)  is  only 
another  way  of  expressing  inherent  weakness,  or  im- 
paired vitality  in  a  certain  direction. 

In  erysipelas,  which  is  an  infectious  disease, 
the  liability  of  communication  from  one  individual  to 
another  is  greatly  influenced  by  the  state  of  health. 
If  two  patients  with  similar  wounds,  the  one  a 
healthy  young  man,  the  other  old  and  broken  down 
by  chronic  kidney  disease,  be  placed  beside  a  case 
of  erysipelas,  the  chances  of  immunity  from,  infection, 
and  recovery  if  infected,  are  greatly  in  favour  of  the 
former  (De  Morgan). 

Further,  closed  abscesses  and,  notably,  empyemata 
often  contain  the  most  foetid  pus  laden  with  bacteria, 
and  yet  the  symptoms  of  septic  intoxication  and 
infection  may  be  almost  nil. 

Considering  the  minute  size  of  the  organisms, 
it  is  difficult  to  suppose  that  the  wall  of  granula- 
tion tissue  bounding  the  abscess  is  so  germ-proof 
as  to  completely  close  all  the  possible  paths  of 
transit. 

The  explanation  then  turns  upon  the  innocuous- 
ness  of  these  organisms,  or  the  vital  strength  of  the 


58  Surgical  Pathology.  [chap.  vii. 

tissues  being  able  to  destroy  them,  Tliu?  much  for 
the  absence  of  infection.  As  to  intoxication,  the  pro- 
ducts of  decomposition,  though  offensive  to  the  sense 
of  smell,  must  be  taken  as  being  not  very  strongly 
pyrogenous,  or  as  being  so  slowly  absorbed  that  the 
tissues  and  excretory  organs  are  able  to  get  rid  of 
them  as  fast  as  they  pass  into  the  system. 

When  the  tissues  have  been  undermined  by  long- 
standing disease,  and  especially  when  they  enclose 
large  collections  of  pus  (as  in  a  psoas  abscess)  they 
offer  but  little  resistance  to  the  absorption  of  septic 
matter.  A  patient  may  be  apyrexial  so  long  as  such 
an  abscess  remains  closed,  but  once  opened  there  is 
an  almost  certainty  of  fever,  perhaps  of  fatal  inten- 
sity, unless  the  ingress  of  germs  be  guarded  against. 
Mr.  Savory  has  shown  that  the  virulence  of  a  blood- 
poison  is  increased  by  the  introduction  of  putrescent 
material  from  another  source. 

In  "  acute  necrosis,"  it  may  be  that  the  infective 
matter  developed  at  the  seat  of  the  local  inflammation 
is  of  itself  sufficient  to  account  for  the  ulterior  con- 
sequences, but  it  is  by  no  means  certain  that  the 
tissues  generally  are  not  strongly  predisposed  to  its- 
action. 

]>iagi[iosis  of  septic  intoxication  and  in- 
fection.— As  septic  intoxication  is  a  concomitant  of 
septic  infection,  the  diagnosis  of  the  latter  must  be 
made  (1)  from  a  knowledge  of  the  transmission  of  the 
blood-poisoned  state  from  one  subject  to  another  by 
means  of  a  very  small  dose  of  the  poison,  or  such  as 
would  appear  inadequate  to  cause  the  symptoms, 
except  on  the  theory  of  multiplication  in  the  system 
(take,  e.g.,  a  case  of  post-mortem  inoculation  with 
the  fluid  from  acute  peritonitis) ;  (2)  by  the  discovery 
of  microscopic  organisms  in  the  blood  and  secretions.  It 
has  been  shown  that  the  presence  of  these  bodies  in 
decomposing   or  putrefying  discharges  from  a  wound 


Chap.  VII.]       Septicemia  and  PvyEMiA.  59 

is  in  itself  no  proof  that  they  must  lead  to  general 
infection. 

On  the  other  hand,  one  would  suspect  septic  intoxi- 
cation alone  where  a  patient  becomes  rapidly  poisoned 
by  absorption  from  a  large  surface  of  gangrenous 
tissue,  and  partic^darly  if  the  escape  of  the  decom- 
posing fluids  be  prevented. 

Pyaemia,  or  purulent  infection,  is  accompanied  by 
more  or  less  septic  intoxication,  but  the  course  of  the 
fever  is  generally  indicated  by  certain  well-defined 
signs  and  symptoms. 

On  pathological  grounds,  septic  intoxication  and 
septic  infection  may  be  considered  as  distinct,  and  on 
clinical,  so  far  as  the  power  of  transmission  from  one 
patient  to  another  is  concerned ;  yet,  as  the  two  con- 
ditions usually  arise  under  similar  circumstances,  and 
as  septic  infection  implies  septic  intoxication,  they 
may  be  described  together  as 

SepticsBmia,  or  "an  acute  blood-poisoning  by 
the  products  of  decomposition  of  the  animal  tissues 
and  fluids  ;  with  or  without  the  development  and 
multiplication  of  infective  organisms  in  various  parts 
of  the  body." 

The  exact  mode  of  action  of  the  poison  is  not  well 
understood.  In  the  main  it  is  probably  chemical. 
The  blood  is  profoundly  affected,  so  that  it  is  unable 
to  nourish  the  tissues.  At  the  same  time,  the  tissues 
themselves  are  so  altered  as  to  be  unfitted  to  carry  on 
their  healthy  functions. 

Character  and  course  of  the  symptoms. — 
The  symptoms  are  chiefly  referred  to  the  nervous 
system,  but  the  effects  of  the  poison  are  manifested  to 
a  greater  or  less  degree  in  the  respiratory  and  circu- 
latory organs  and  the  alimentary  canal.  Cases  differ 
somewhat  from  one  another  in  the  relative  frequency 
and  extent  with  which  the  different  structures  are 
affected.      In    the    artificially-induced    septicaemia    of 


6o  Surgical  Pathology.  [Chap. vii. 

dogs  the  intestinal  tract  suffers  considerably.  The 
nervous  symptoms  are  those  of  rapidly-increasing 
prostration  and  narcotism.  The  patient  becomes 
apathetic  and  somnolent.  In  many  instances  there  is 
low  muttering  delirium,  gradually  passing  into  coma. 
More  rarely  the  mind  is  quite  clear  until  the  fatal  end. 
Headache  is  not  prominent.  There  are  either  no 
rigors,  or  only  an  initial  cliill  that  ushers  in  the  other 
symptoms.  Muscular  weakness  quickly  supervenes. 
This  is  shown  by  failing  power  of  the  heart,  the 
inability  to  sustain  exertion,  and,  it  may  be,  general 
tremor  of  the  body. 

The  teinperature  varies  considerably.  Sometimes 
it  is  very  high,  104°  F.  or  more  ;  in  others  there  is  but 
little  change  ;  or.  again,  it  may  be  subnormal  from 
the  first,  and  this  often  in  the  worst  cases.  Hence, 
taken  alone,  it  helps  very  little  in  the  prognosis.  We 
do  not  find  the  steep  fever  curves  as  in  pyaemia. 

It  may  rise  considerably  after  death.  I  have 
known  it  to  reach  108°  P.  This  is  due  to  rapid 
destruction  of  the  tissues,  and  the  non-conversion  of 
heat  into  functional  power. 

The  respirations  become  quick  and  shallow  from 
muscular  weakness,  and  hurried  still  more,  perhaps, 
from  pulmonary  congestion  and  stasis. 

The  bowels  are  constipated  in  some  cases,  relaxed 
in  others.  Blood  and  mucus  may  be  passed  in  the 
stools.     There  is  sometimes  uncontrollable  vomiting. 

State  of  the  blood  and  urine.  —  If  a  drop  of 
blood  be  placed  on  a  slide,  the  red  corpuscles  will  be 
seen  to  gather  into  clumps  rather  than  rouleaux,  but 
they  show  nothing  definite  in  outline. 

The  white  corpuscles  are  relatively  and  absolutely 
increased.     Micrococci  and  bacteria  may  be  present. 

The  urine  is  high-coloured  ;  it  is  acid,  but  quickly 
becomes  alkaline  when  passed.  The  urea  and  uric 
acid   are   increased.      The   phosphates,    potash    salts, 


Chap.  VII.]       Septicemia  and  Pyemia.  6i 

and  chlorides  are  diminished.  Biliary  constituents 
are  occasionally  present. 

Colour  of  the  skin.  —  The  skin  has  a  dusky 
earthy  tint,  or  it  is  distinctly  yellow.  This  may  be 
from  bile-staining,  but  it  is  probably  tinted  with 
blood  pigment  set  free  by  disintegration  of  the  red 
corpuscles. 

Post-mortem  sigrms. — Rigor  mortis  sets  in  early 
and  soon  disappears.     Decomposition  is  very  rapid. 

The  blood  coagulates  imperfectly.  It  may  be 
almost  fluid.  It  is  said  sometimes  to  be  tarry,  but  I 
have  never  seen  this. 

Disintegration  of  the  red  corpuscles  goes  on  during 
life ;  this  is  shown  by  the  staining  of  the  endo- 
cardium and  the  intima  of  the  vessels,  observed 
directly  after  death. 

The  serum,  too,  is  more  or  less  deeply  tinged,  and 
dark  from  deoxidation  of  the  haemoglobin.  Micro- 
cocci are  sometimes  present  (septic  infection). 

The  internal  organs  show  marked  congestion, 
especially  at  the  most  dependent  parts. 

Thrombosis  is  very  common,  and  capillary  ex- 
travasation far  from  rare.  The  latter  is  most  marked 
in  the  mucous  and  submucous  coats  of  the  intestine, 
and  beneath  the  serous  membranes  in  the  form  of 
pelechise  or  more  diffuse  extravasations.  Meningeal 
haemorrhage  is  less  frequent. 

There  are  several  factors  at  work  in  causing  the 
coagulation  in  the  vessels  :  1.  A  ferment  is  supposed 
to  be  liberated  by  the  breaking  up  of  the  white 
corpuscles  (Kohler).  2.  The  chemical  composition  of 
the  blood  is  greatly  altered.  3.  Stasis  from  weak  pro- 
pelling power  of  the  heart.  4.  Swelling  and  shedding 
of  the  endothelium  of  the  vessels,  the  debris  obstruct- 
ing the  lumen.  5.  Encroachment  of  the  thickened 
intima  upon  the  vascular  channels.  The  hyperplasia 
is    found  in    the    small    arteries    f"  obliterative    end- 


62  Surgical  Pathology.  [Chap.  vii. 

arteritis ")  not  in  the  venules ;  these,  however,  may- 
show  inflammatory  changes  secondary  to  thrombosis.* 
6.  Aggregation  of  micrococci. 

The  mechanism  of  the  haemorrhage  is  thus  ex- 
plained :  1.  The  walls  of  the  vessels  are  degenerated 
through  {a)  starvation,  from  the  blood  supply  being 
cut  off  by  coagulation  ;  (6)  fatty  metamorphosis,  from 
high  temperature,  and  the  blood-poisoning.  2.  Capil- 
lary thrombosis  leading  to  venous  reflux,  and  conse- 
quent rise  of  tension  in  the  congested  areas. 

But  "  frequently  the  internal  organs  present  no 
morbid  appearances  "  (Billroth),  or  at  least  none  that 
are  characteristic.  More  often  the  above-described 
congestions,  thromboses,  and  haemorrhages,  singly  or 
in  combination,  are  met  with,  and  as  a  rule  the 
parenchyma  is  softer  than  natural  from  acute  granulo- 
fatty  change. 

The  siileen  is  enlarged,  soft,  and  congested.  The 
liver  is  greasy,  of  a  dirty  yellowish  gray  colour.  Its 
blood-vessels  are  full,  esj)ecially  those  of  the  hepatic 
venous  system.  The  tissue  may  be  bile-stained. 
Crystals  of  tyrosin  have  been  found. 

The  kidney  is  enlarged  ;  the  epithelium  is  granular 
and  swollen.  Exudation  is  occasionally  seen  between 
the  Malpighian  glomeruli  and  capsules.  The  sub- 
capsular stellate  veins  are  injected,  and  the  whole 
organ  is  more  or  less  congested.  There  may  be  capil- 
lary extravasations  between  and  into  the  tubes.  The 
latter  are  often  choked  with  epithelial  debris. 

The  lungs  are  congested,  and  oedematous.  Patches 
of  collapse  and  diffuse  thrombosis,  with  or  without 
extravasation,  may  be  noticed. 

The  loleura  and  pericardium  sometimes  contain 
blood-stained  serum.  The  brain  is  congested  ;  more 
rarely  it  is  the  seat  of  meningeal  extravasation.     If 

*  Vide  Trans.  Path.  Soc,  vol.  xxx,,  p.  53. 


Chap.  VII.]       Septicemia  and  Pyaemia.  63 

the  skin  presented  a  dusky  jaundiced  tint  during  life, 
this  will  be  found  in  the  cadaver. 

In  septic  infection  groups  of  micrococci  often 
crowd  the  different  tissues.  They  occupy  the  vessels 
and  the  intervascular  spaces  in  the  various  organs. 

The  above-described  symptoms  and  post-mortem 
signs  may  be  taken  as  those  of  a  constructive  case  of 
septicaemia,  rather  than  as  constant  and  necessary 
phenomena.  Many  of  them  are  rarely  absent,  and 
most  or  all  may  be  present.  They  are  also  found 
with  undiminished  intensity  in  acute  pysemia ; 
but  anatomically  pyaemia  is  septicaemia  plus  metas- 
tases. 

Fysemia.  synonyms. —  Purulent  diathesis,  puru- 
lent infection.  Pus  disease.  Ichorhaemia  (Yirchow). 
Pyohaemia  simplex  et  multiplex,  i.e.,  pyaemia  with 
or  without  metastases  (Hueter).  The  last-mentioned 
designation  corresponds  to  what  we  regard  as  septi- 
caemia and  pyaemia  respectively. 

History  and  current  views  of  pyaemia. — 
The  name  pyaemia  was  given  to  the  disease  by 
Piorry.  The  supposed  necessary  dependence  upon 
absorption  of  pus  seemed  indicated  (1)  by  the  constant 
association  of  pus  formation  and  the  characteristic 
lesions;  (2)  by  the  discovery  of  cells  and  granular 
bodies  in  the  blood,  which  were  believed  to  be  de- 
rived from  segmentation  of  connective  tissue  cor- 
puscles (the  leucocyte  migration  theory  was  not  then 
in  vogue). 

We  now  know  that,  whether  the  pus  cells  do  or 
do  not  pass  back  into  the  vessels,  they  come  from  them 
in  the  first  instance.  Probably  the  corpuscular  and 
granular  masses  thought  to  be  simply  altered  pus  were 
in  many  instances  decolorised  thrombi,  set  free  by 
disintegration.  (Vide  Thrombosis.)  Billroth  insists 
that  "  reabsorption  of  pus  is  the  cause  "  of  pyaemia ;  but 
his  statements  with  regard  to  metastases  are  somewhat 


64  Surgical  Pathology.  [Chap.  vit. 

at  variance;  thus,  lie  says,  "metastatic  inflammations 
are  very  essential  anatomical  conditions;"  and,  again, 
^'  purulent  infection "  (pyaemia)  sometimes  occurs 
"without  a  trace  of  metastases."  The  latter  condition 
corresponds  to  what  we  have  described  as  septic 
infection,  with  this  difference,  that  we  did  not  consider 
pus  to  be  a  necessary  factor  in  the  process. 

Koch,  who  states  that  "pysemia  does  not  arise, 
as  was  formerly  supposed,  from  the  entrance  of  pus 
into  the  vessels,"  looks  upon  the  disease  as  a  general 
one,  accompanied  by  metastatic  inflammations.  This 
is  the  light  in  which  we  regard  it,  viz,,  that  pyaemia 
is  septic  infection  with  metastases. 

Although  the  simple  absorption  of  pus  does  not 
express  the  exact  truth,  it  must  be  remembered  that 
suppuration  is  a  very  constant  coincidence,  for  it  is 
found  in  those  extremely  rapid  cases  where  pyaemia 
follows  acute  necrosis,  and,  h  fortiori^  where  a  longer 
time  is  given  for  the  development  of  the  primary  and 
secondary  inflammations. 

Causes  of  metastases.  —  The  occurrence  of 
metastases  may  be  explained  in  three  ways  :  (1)  On 
the  assumption  that  pyaemia  is  a  distinct  and  specific 
affection ;  (2)  by  the  products  of  decomposition,  local 
and  disseminated,  being  unusually  irritating  to  the 
tissues,  which,  in  their  turn,  may  be  prone  to  undergo 
inflammatory  changes ;  (3)  by  embolism,  from  venous 
thrombi  soaked  in  septic  matter.  In  favour  of  the 
first  of  these  views  is  the  fact  of  the  disproportion  of 
the  tissue  changes  to  the  degree  of  septic  intoxication 
in  all  but  very  acute  cases.  But  then  a  poison  may 
be  highly  phlogogonous,  whilst  its  intoxicating  and 
pyrogenous  qualities  are  comparatively  slight.  Koch 
says  that  the  terms  pyaemia  and  septicaemia  "  have 
only  remained  in  use  as  general  names  for  a  number 
of  symptoms  which  most  probably  belong  to  a  series 
of  different  diseases." 


Chap.  VII.]       Septicemia  and  Pymmia.  65 

Course  and  character  of  the  symptoms. — 

Pyaemia  is  a  continuous  fever  with  very  decided  inter- 
missions. This  seems  to  show  that  the  pyrogenous 
matter  thrown  into  the  blood  is  largely  derived  from 
the  foci  of  the  secondary  or  metastatic  inflammations, 
for  the  intervals  and  accessions  appear  too  marked  to 
be  explained  by  absorption  from  the  primary  wound, 
or  phlegmon,  which  may  to  all  appearance  be  taking  a 
steady  continuous  course.  Billroth,  however,  believes 
that  "  extensive  progressive  inflammation  about  the 
wound  must  be  regarded  as  the  chief  source  of  such 
repeated  purulent  infection." 

The  fever  is  ushered  in  by  symptoms  of  general 
malaise,  or  by  an  initial  chill.  The  temperature  rises 
before  the  occurrence  of  the  rigor.  Both  are  due  to 
the  same  cause,  viz.,  a  charging  of  the  blood  with 
poisonous  matter,  which  first  induces  increased  meta- 
bolism of  the  tissues,  and  then  disturbs  the  equilibrium 
of  the  motor  centres.  The  sensation  of  cold  is  caused 
either  by  (1)  the  rapid  elevation  of  the  surface  tem- 
perature, or  by  (2)  "  the  blood  being  driven  from  the 
capillaries  by  the  spasm  of  the  cutaneous  muscles  " 
(Billroth).  The  heat  of  the  body  may  rise  to  105"  F., 
or  even  higher;  it  is  to  some  extent  proportionate  to 
the  nervous  irritability  of  the  patient,  and  so  is  the 
severity  of  the  rigor.  At  the  end  of  this  stage  profuse 
perspiration  occurs  and  the  temperature  falls,  some- 
times below  the  normal,  but  even  then  it  rises  again, 
so  that  the  fever  is  practically  continuous.  In  this 
way  it  difiers  from  ague,  which  in  some  respects  it 
greatly  resembles. 

The  chills  and  exacerbations  are  repeated  at 
varying  intervals.  This  is  characteristic  of  the  disease. 

The  severity  of  the  nervous  and  other  symptoms 

depends  in  great  measure  upon  the  acuteness  of  the 

fever.      In   pyaemia   from    "acute   necrosis"    all    the 

signs  of  septic  intoxication  are  well  marked.     In  the 

p 


66  Surgical  Pathology.  [Chap.  vii. 

sub-acute  and  chronic  forms  the  mind  is  generally 
quite  clear. 

Meanwhile  the  patient  rapidly  loses  flesh,  for 
whilst  his  tissues  are  being  burnt  up  they  are  not 
replaced,  owing  to  defective  assimilation. 

The  countenance  assumes  a  cachectic  hue,  the 
features  are  drawn,  and  are  expressive  of  extreme 
exhaustion  rather  than  acute  suffering.  Towards  the 
end  the  tongue  becomes  dry  and  brown,  and  the 
tainted  sweetness  of  the  breath  more  marked.  Bed-sores 
are  common. 

The  jjrogyiosis  turns  upon  (1)  the  possibility  of 
getting  rid  of  the  primary  source'  of  infection;  (2) 
the  extent  and  situation  of  the  metastases;  (3)  the 
duration  of  the  fever.  Every  day  that  passes  adds  to 
the  probability  of  recovery. 

€hang:e$  in  tlie  ground. — The  suppurative 
inflammation  at  first  increases,  in  direct  continuity, 
and  by  the  formation  of  abscesses  at  some  little 
distance  beyond.  The  pus  is  thin — ichorous,  as  it  is 
termed.  Later  on,  the  wound  becomes  drier.  Any 
granulations  that  have  formed  are  destroyed.  The 
neighbouring  veins  are  frequently  thrombosed,  and  on 
cutting  into  them  they  are  found  to  contain  clots  in 
various  stages  of  formation  and  disintegration.  The 
nearest  lymphatic  glands  are  enlarged. 

Metastases. — During  life  localised  and  diffuse 
suppurations  may  be  met  with  ;  especially  in  the  joints, 
viscera,  and  the  subcutaneous,  subfascial,  and  inter- 
muscular connective  tissue.  The  rapidity  with  which 
these  abscesses  form  is  often  remarkable.  Then,  again, 
there  may  be  evidence  of  pneumonia,  pleurisy,  and 
pericarditis.  In  rarer  cases  the  eye-ball  is  destroyed, 
and  cerebral  abscess  or  suppuration  in  the  arachnoid 
may  ensue 

Post-mortem  appearances. — Except  in  very 
acute   cases,  where   during   life   the   signs   of  septic 


Chap.  VII.]  SePTICMMIh    AND    PyMMIA.  67 

intoxication  were  well  marked,  there  may  be  nothing 
very  striking  to  be  seen  post-mortem  in  the  state  of 
the  blood  j  and  the  internal  organs  do  not  show  such 
extensive  congestions,  thromboses,  haemorrhages,  and 
softenings  as  described  under  septicaemia.  But  there 
are  quite  characteristic  lesions  in  the  form  of  multiple 
circumscribed  metastatic  abscesses,  and  red  infarctions 
in  various  stages  of  softening  and  suppuration.  These 
are  for  the  most  part  wedge-shaped,  and  are  then 
evidently  the  result  of  septic  embolism.  The  contents 
of  the  abscesses  consist  of  disintegrated  tissue  and 
blood  clot,  mingled  with  pus.  They  are  most  fre- 
quently seen  in  the  lungs,  but  they  are  not  uncommon 
in  the  spleen,  kidney,  and  other  organs. 

More  rarely  the  abscesses  are  scattered,  appa- 
rently irrespective  of  the  course  of  the  circulation. 
These,  and  the  occasional  diffuse  suppurations,  are 
probably  the  consequence  of  primary  thromboses,  and 
of  the  phlogogonous  action  of  the  poison  upon  tissues 
predisposed  to  inflammation.  The  same  may  be  said 
of  suppuration  in  the  joints. 

The  primary  wound  will  be  found  infiltrated  with 
pus,  and  the  veins  usually  filled  with  disintegrating 
clots. 

Such  is  a  typical  case  of  pyaemia  j  but  the  signs  of 
septicaemia  and  pyaemia  may  be  found  in  almost 
endless  combinations ;  "  for  instance,  se'pticcemia  occurs 
without  a  trace  of  metastases,  with  metastases,  with 
thrombosis  and  embolism  ;  'purulent  infection  (pyaemia) 
without  a  trace  of  metastases,  with  diffuse  metastases 
and  thrombi,  with  thrombi  alone,  with  thrombi  and 
emboli  ;  there  are  thrombi  with  local  sequences  with- 
out emboli,  with  emboli,  with  haemorrhagic  effusions, 
with  apoplexies,  etc.  (Billroth). 

Idiopatbic  pysBinia.  —  Sometimes  numerous 
abscesses  attended  with  other  pyaemic  symptoms  are 
met  with,  without  our  being  able  to  trace  their  origin  ; 


6^8  Surgical  Pathology.  [Chap. vii. 

but  then  the  source  of  infection  may  be  some  poison 
that  has  gained  access  to  the  organism  by  the  re- 
spiratory tract,  or  through  some  minute  focus  of  in- 
flammation in  the  alimentary  canal. 

"  Acute  necrosis "  seems  to  form  the  link  in  the 
etiological    chain    between    these    and   the    ordinary 
cases  of  traumatic  pysemia. 
•    Suppression  of  Urine — Urethral  Fever. 

Suppression  of  iirine  is  obstructive  or  non- 
obstructive. In  the  former  case  it  generally  follows 
impaction  of  a  calculus  in  one  ureter,  the  kidney  on 
the  other  side  having  previously  been  incapacitated 
by  disease.  The  condition  of  the  patient  is  peculiar, 
for  whilst  the  suppression  may  last  a  week  or  more, 
the  urinous  odour  of  the  breath  is  usually  absent,  and 
there  is  no  dropsy. 

The  passage  of  a  catheter  has  been  known  to 
cause  death  within  a  feAV  hours.  The  pathology  of 
such  cases  is  somewhat  complex.  It  cannot  be  ex- 
plained by  simple  reflex  congestion  of  the  kidney,  for 
the  organ  may  not  be  flooded  with  blood  to  the  extent 
that  one  would  sujopose  necessary  to  account  for  the 
total  abrogation  of  function.  It  may  be  that  the  nerve 
irritation  affects  the  secreting  cells  directly.  The 
suddenness  of  onset  and  the  absence  of  a  large 
wounded  surface  preclude  the  assumption  of  acute 
septic  intoxication  being  the  cause ;  but  probably 
all  the  above-mentioned  factors  combine  in  their 
action. 

Uretliral  fever  is  the  name  given  to  the  general 
state  caused  by  some  injury  to  the  urethra,  such  as 
internal  urethrotomy,  or  forcible  dilatation,  or  even 
simple  catheterism.  It  is  frequently  ushered  in  by  a 
rigor  which  may  be  repeated.  The  temperature 
rises  rapidly.  The  other  symptoms  of  fever  are 
present.  Then  there  is  sweating,  and  with  it  a  quick 
decline  in  the  body-heat.     Whilst  the  fever  lasts,  but 


Chap.  VIII.]  Erysipelas.  69 

little  urine  is  passed ;  witli  its  disappearance  there 
is  often  a  copious  flow. 

Sometimes  a  considerable  amount  of  blood  is  lost, 
and  this  seems  to  come  from  the  kidney,  for  it  is  well 
mixed  with  the  urine,  unless  in  such  quantity  as  to 
coagulate  in  the  bladder,  a  circumstance  which  has 
happened  twice  in  the  author's  practice  (once  after 
Holt's  dilatation  and  once  after  easy  catheterism), 
and  its  effusion  is  attended  with  decided  relief  from 
pain  in  the  back.  The  cause  of  the  fever  is  apparently 
fourfold  :  (1)  Keflex  congestion  and  consequent  im- 
pairment of  function  of  the  kidney ;  (2)  stimulation 
of  the  nerves  of  an  unusually  sensitive  tract ;  (3) 
absorption  of  poisonous  matter,  though  this  must  be 
very  slight  in  those  cases  where  but  little  or  no  injury 
is  done  to  the  urethra  j  (4)  nervous  irritability  of  the 
patient. 

I  have  known  it  ensue  more  than  once  in  the  same 
case  upon  the  withdrawal  of  a  catheter  which  had 
lain  in  the  bladder  for  48  hours  without  causing  the 
least  disturbance. 


CHAPTER   YIII. 

ERYSIPELAS. 

Erysipelas  is  generally  described  as  existing  under 
three  forms :  (1)  Simple  cutaneous  erysipelas ;  (2) 
phlegmonous  or  cellulo-cutaneous  erysipelas  ;  (3) 
cellulitis ;  though  it  is  by  no  means  certain  that  the 
poison  is  the  same  in  each  case. 

Those  who  believe  in  the  unity  of  the  disease 
explain  the  difierent  results,  (1)  By  the-  mode  of 
introduction  of  the  virus ;  (2)  by  the  degree  of  its 
concentration ;  (3)  by  the  extent  to  which  the  cuta- 


yo  Surgical  Pathology.  [Chap. viii. 

neous  and  subcutaneous  tissues  are  predisposed  to  its 
action.  There  is  also  the  fact  of  one  variety  taking 
on  the  characters  of  another.  This  is  especially  the 
case  in  the  cutaneous  and  cellulo-cutaneous  forms. 
The  former  may  end  in  suppuration,  and  the  latter 
spread  superficially  as  a  capillary  lymphangitis ;  and 
both  may  arise  without  the  previous  existence  of  a 
broken  surface  of  skin  or  mucous  membrane.  Cellu- 
litis appears  to  be  always  preceded  by  a  wound, 
although  this  is  often  very  slight.  Moreover,  it  may 
be  excited  by  poisons  of  widely  different  nature ; 
e.g..,  that  of  venomous  animals,  unhealthy  matter 
from  inflammatory  foci,  or  cadaveric  fluids. 

Simple  cutaneous  erysipelas  is  generally 
due  to  inoculation  or  infection  of  a  wounded  surface 
(Billroth,  Trousseau);  for  the  so-called  idiopathic 
variety  usually  attacks  the  exposed  parts  of  the 
body,  particularly  the  face,  or  those  most  subject 
to  scratches  or  abrasions,  which  may  be  so  small  as 
to  pass  unnoticed. 

The  general  predisposing  causes  are  bad  hygienic 
conditions  and  impaired  health  of  the  patient. 

The  actual  cause  is  the  specific  poison  com- 
municated by  direct  inoculation,  or  infection. 

The  disease  is  not  highly  infectious,  but  there  can 
be  no  doubt  as  to  this  mode  of  transmission,  as  shown 
by  the  occurren<?e  of  epidemics  and  sporadic  cases. 

That  it  is  of  the  n^^ture  of  an  exanthem  is  proved 
by  there  being  a  period  of  inoculation  followed  by  an 
efflorescence  or  rash.  It  is  peculiar  in  taking  an 
irregTilar  course,  and  in  not  conferring  protection  from 
subsequent  attacks. 

Morbid  anatomy. — Erysipelas  may  be  defined 
as  a  specific  superficial  capillary  lymphangitis.  The 
nearest  lymphatic  glands  are  always  enlarged  and 
tender,  though  they  rar  ly  suppurate.  The  swelling 
may  be  noticed  in  them  before  the  rash  is  manifest. 


Chap.  VIII.]  Erysipelas.  71 

The  affected  skin  is  of  a  bright  red  or  pink  colour. 

It  is  swollen  and  oedematous,  so  that  pressure 
causes  decided  pitting.  The  margin  of  the  eruption 
is  generally  well  defined,  and  raised  above  the  surface 
of  the  healthy  skin,  though  at  times  it  is  indistinct 
and  difficult  to  differentiate  from  that  of  simple 
erythema ;  but  then  the  diagnosis  can  be  made  by  the 
constitutional  symptoms  which  are  quite  pronoTinced, 
whereas  in  erythema  there  is  little  or  no  general  dis- 
turbance. 

The  part  is  tender  to  the  touch. 

The  exudation  which  causes  the  skin  to  feel  firm 
and  inelastic  may  be  confined  to  the  interstices  of  the 
subcutaneous  tissue  and  the  papillary  layer ;  or  raise 
the  epidermis  into  vesicles  which,  by  their  coalescence, 
may  form  bullae.  The  fluid  in  the  vesicles  is  usually 
clear  and  pale,  occasionally  it  is  blood-stained  ;  this 
depends  upon  the  degree  of  vascular  tension  and  dis- 
integration of  the  red  blood-corpuscles.  The  vesicles 
and  bullae  dry  up  or  burst,  leaving  scabs  without 
ulceration. 

As  the  inflammation  spreads  at  the  periphery, 
it  dies  away  in  the  parts  first  involved.  This  would 
seem  to  prove  that  the  poison  had  worn  itself  out,  or 
that  the  tissues  had  become  insusceptible  to  its  further 
influence. 

When  the  cellular  tissue  is  very  abundant  and  lax 
suppuration  may  occur ;  this  is  most  common  in  the 
scalp  and  eyelids. 

The  surface  of  the  wound  (if  one  exists)  looks 
unhealthy,  grayish,  and  secretes  but  little  pus.  De- 
squamation ensues  on  the  subsidence  of  the  inflam- 
mation, and  the  skin  is  left  slightly  stained. 

As  before  stated,  erysipelas  may  attack  the 
mucous  membrane  of  the  mouth,  nose,  and  pharynx. 
It  there  causes  considerable  oedema,  and  there  is 
danger  from  swelling  about  the  glottis. 


72  Surgical  Pathology.  [Chap.  vin. 

Microscopy. — The  skin  is  infiltrated  with  leu- 
cocytes, and  the  subcutaneous  cellular  tissue  fibres 
are  swollen,  and  more  or  less  dissociated  by  the 
exudation. 

Where  the  morbid  changes  are  active,  the  lym- 
phatics are  said  to  contain  micrococci  (Lukomsky). 

The  lymph  spaces  and  vessels  may  be  choked 
with  wandering  cells.  The  white  corpuscles  while 
contained  within  the  vessels  have  been  found  en- 
larged, and  highly  granular  and  refractive,  possibly 
from  the  presence  of  micrococci. 

The  g-eaieral  symptoms  appear,  as  a  rule, 
before  the  local — twenty-four  hours,  or  less.  At  the 
commencement,  the  patient  experiences  a  sensation  of 
cold ;  more  rarely  there  is  an  initial  rigor,  and  in 
children  convulsions.  The  temperature  rises  to  104° 
Fahr.,  or  higher.  There  are  no  marked  exacerbations, 
unless  the  disease  takes  an  irregular  course  with 
relapses.  In  the  old  and  very  young,  and  in  those 
exhausted  by  previous  suffering,  the  symptoms  may 
be  asthenic  from  the  first. 

The  duration  of  the  fever  is  indefinite. 

Post-mortem  appessraiices.  —  Locally,  as 
above  described.  Internally  nothing  may  be  observed 
beyond  the  general  signs  indicative  of  continued  high 
fever. 

In  very  malignant  cases  there  may  be  evidence  of 
acute  blood-poisoning — septicaemia  {q-v.). 

The  small  vessels  of  the  lung  (Busk)  and  of  the 
brain  (Bastian)  have  been  described  as  containing 
masses  of  granular  leucocytes. 

Erysipelas  associated  \¥itSi  septicsemia. — 
This  is  rather  a  coincidence  than  a  transmutation 
of  two  diseases,  probably  quite  distinct. 

Erysipelas,  by  seriously  impairing  the  vitality 
of  the  tissues,  renders  them  very  susceptible  to  the 
action  of  poisons  capable  of  setting  up  infective  pro- 


Chap.  VIII.]  Erysipelas.  73 

cesses.  It  is  well  seen  where  puerperal  fever  de- 
velops in  women  wlio  have  been  exposed  to  the 
infection  of  erysipelas. 

Erysipelatous  lymphangitis. — We  have  said 
that  cutaneous  erysipelas  is  always  and  essentially  a 
lymphangitis,  though  all  the  tissue  elements  of  the 
part  are  necessarily  affected.  But  the  variety  under 
notice,  instead  of  spreading  simply  or  mainly  by 
continuous  implication  of  the  local  capillaries,  follows 
the  course  of  the  lymphatic  trunks  from  the  seat  of 
primary  infection  to  the  next  group  or  groups  of 
lymph  glands,  in  this  way  resembling  syphilis.  Thus, 
a  wound  on  the  inner  side  of  the  hand  or  forearm 
sets  up  specific  inflammation  of  the  lymphatics  that 
join  the  supra-condyloid  and  axillary  glands.  The 
path  of  transit  of  the  poison  is  marked  by  a  series  of 
red  lines  which  remain  distinct,  or  become  fused  as 
the  hypersemia  extends.  The  lymphatics,  and  the 
lymph-paths  in  the  glands,  become  blocked,  and  thus 
the  infective  matter  is  to  a  great  extent  arrested  in 
its  course  to  the  blood  stream.  Suppuration  not  un- 
commonly occurs  in  the  glands,  and  in  the  cellular 
tissue  about  the  obstructed  vessels,  as  the  result  of  the 
irritation  of  the  poison  there  accumulated. 

PMegmionous  or  celliilo-cutaneoiis  ery- 
sipelas.— This  variety  of  erysipelas  occurs  most 
frequently  in  the  upper  limb.  It  may  arise  sponta- 
neously, or  follow  a  wound.  It  is  characterised  by 
intense  inflammation  of  the  skin  and  subcutaneous 
cellular  tissue.  At  first  the  affected  part  is  bright  red, 
cedematous,  painful,  and  exceedingly  tender  to  the 
touch.  As  the  tension  increases  the  skin  assumes  a 
shining  aspect,  and  feels  hard  and  brawny.  Later  on, 
the  diffused  redness  becomes  varied  by  deep  maroon- 
coloured  patches  of  congestion  and  thrombosis,  and 
here  and  there  a  bogginess  can  be  detected,  indicating 
the  breaking  down  of  the  subcutaneous  tissues.      Or 


74  Surgical  Pathology.  [Chap.  viii. 

there  may  be  distinct  fluctuation,  especially  where  the 
phlegmon  is  comparatively  circumscribed.  Meanwhile 
the  skin  is  destroyed  by  a  combination  of  purulent 
liquefaction  and  gangrene.  The  openings  made  by 
the  surgeon,  or  established  spontaneously,  give  vent 
to  the  discharge,  which  is  very  profuse,  and  composed 
of  pus  in  which  shreds  and  flakes  of  sloughy  cellular 
tissue  are  suspended.  Unless  there  be  a  wound,  the 
signs  of  putrefaction  (off"ensive  smell,  and  emphy- 
sematous crackling  from  the  evolution  of  gases)  are 
absent.  The  process  is  so  rapid  that  the  greater  part 
of  the  integument  of  the  forearm  may  be  destroyed 
within  a  week,  and  the  muscles  and  tendons  laid  bare, 
or  covered  only  with  dirty  gray  sloughs.  From  the 
paucity  of  vessels,  and  the  strangulation  by  the  high 
tension  of  those  that  exist,  the  tendons  frequently 
necrose. 

As  the  cellular  tissue  melts  away  more  quickly 
than  the  skin,  the  latter  becomes  undermined  for  a 
considerable  distance,  and  the  finger  passed  beneath 
it  meets  with  no  obstruction,  or  only  from  some 
isolated  fibrous  bands  that  carry  the  blood-vessels  from 
the  deeper  parts  to  the  skin.  These  vessels  are  often 
plugged  with  clots,  and  this  hastens  the  death  of  the 
structures  to  be  supplied.  Care  should  be  taken  not 
to  break  them  through,  as  profuse,  dangerous,  and 
even  fatal  haemorrhage  might  be  caused  thereby,  the 
more  so  if  the  cellulitis  has  reached  some  very 
extensive  cellular  tract,  as  the  axilla,  or  subpectoral 
space.  After  the  surface  is  broken,  decomposition  of 
the  fluids  and  dead  tissues  is  set  up,  and  then  the 
danger  of  septic  intoxication  and  pyaemia  is  very  great. 

The  inflammation  seems  in  some  cases  to  start 
in  the  sheaths  of  the  tendons  (phlegmonous  teno- 
synovitis), constituting  one  form  of  whitlow.  The 
lymphatic  glands  are  not  always  enlarged.  The 
general  symptoms  are  those  of  intense  inflammatory 


Chap.  VIII.]  Erysipelas.  75 

fever:  the  temperature  reaches  105°Fahr.  ;  there  is 
complete  anorexia  and  great  nervous  exhaustion ;  the 
tongue,  at  first  moist  and  thickly  coated^  tends  to 
become  dry  and  brown,  and  sordes  form  about  the 
teeth.  Death  takes  place  from  exhaustion,  or  acute 
blood-poisoning. 

Phlegmonous  erysipelas  differs  from  the  simple 
cutaneous  form  in  the  intensity  of  the  inflammation, 
and  the  absence  of  a  defined  margin  to  the  redness 
and  swelling.  The  points  of  resemblance  are  (1)  that 
one  form  may  excite  the  other ;  (2)  that  both  may 
occur  as  epidemic  outbreaks. 

€elluliti§. — The  pathology  of  cellulitis  is  much 
the  same  as  that  of  phlegmonous  erysipelas,  but  the 
skin  is  not  primarily  involved. 

The  inflammation  spreads  with  great  rapidity 
along  the  subcutaneous  and  intermuscular  planes  of 
connective  tissue.  It  is  almost  if  not  always  started 
by  a  wound.  The  part  becomes  swollen  and  oedematous, 
then  boggy  or  indistinctly  fluctuating.  As  the  cellular 
tissue  is  destroyed,  the  skin,  cut  off  from  its  blood- 
supply,  may  become  gangrenous.  There  may  be 
scarcely  any  change  at  the  seat  of  inoculation,  and 
yet  the  most  wide-spread  suppuration  and  sloughing 
of  the  areolar  tissue  beyond. 

In  pelvic  cellulitis  following  operations,  or  partu- 
rition, the  inflammation  sometimes  spreads  to  the 
peritoneum,  but  not  necessarily  so.  I  have  known 
the  serous  surface  to  retain  its  lustre  whilst  suppuration 
had  exten'ded  from  a  lithotomy  wound,  along  the 
course  of  the  ureter  to  the  kidney.  In  injuries  to  the 
scalp  the  destruction  is  sometimes  so  extensive  that 
the  entire  galea  aponeurotica  rides  upon  a  bed  of  pus. 

Cellulitis  of  the  neck  may  be  very  extensive.  It 
usually  follows  some  operation,  or  starts  in  inflamma- 
tion of  the  pharynx  or  tonsil,  set  up  by  a  wound  or 
inoculation  with  infective  matter. 


76  Surgical  Pathology.  [Chap.  ix. 

Tlie  lymphatic  glands  are  enlarged,  but  they  do 
not  often  suppurate,  although  they  may  be  found 
gangrenous  in  the  sloughy  debris  that  surround  them. 

The  constitutional  symptoms  are  strongly  marked 
— high  fever  and  asthenia,  quickly  ending  in  death 
unless  relief  is  given  by  early  incisions.  The  disease 
is  very  fatal  in  all  its  forms,  but  in  no  other  more 
surely  and  rapidly  than  after  post-mortem  wounds  with 
inoculation  of  the  poison  from  diffuse  inflammation, 
such  as  peritonitis. 


CHAPTER  IX. 

FURUNCLE,  CAUBUNCLE,  AND  MALIGNANT  PUSTULE. 

Furuncles,  or  boils,  are  localised  inflammations 
of  the  skin  and  subcutaneous  tissue.  When  occurring 
singly  they  probably  have  a  purely  local  origin  in 
some  extrinsic  irritation,  or  in  the  pent-up  secretions 
of  the  cutaneous  glands  ;  hence  their  frequency  in 
the  axillae  and  perineum.  When  multiple  (furuncu- 
losis)  they  are  generally  considered  as  the  expression 
of  an  unhealthy  state  of  the  blood.  There  can  be  no 
doubt  but  that  they  are  most  frequent  in  persons  out 
of  health,  whether  the  cause  be  transient  or  abiding. 
Diabetes  and  chronic  kidney  disease  predispose  to 
them.  The  proximate  cause  seems  to  be  an  irritation 
of  the  glandular  structures  of  the  skin  by  soine  peccant 
material  circulating  in  the  blood. 

Morbid  anatoxuy. — The  blood  stagnates  and 
then  coagulates  in  the  capillary  areas  about  the 
sudoriparous  and  sebaceous  glands.  This  entails 
death  of  the  part^  and  inflammation  around  the 
thrombosed  vessels.  As  the  tissues  melt  away  a  bed 
of  pus  is  formed,  and  the  little  isolated  gangrenous 


Chap.  IX.]  Carbuncle.  77 

plug  comes  away  as  a  slougli,  or  it  liquefies.  The 
further  progress  is  that  of  a  small  acute  abscess. 
More  rarely  the  inflammation  subsides  without  the 
occurrence  of  suppuration,  and  the  swelling  is  then 
termed  a  "blind  boil."  However  acute  the  inflam- 
mation it  never  spreads  to  the  surrounding  parts. 

Carbuncle.  —  A  carbuncle  may  be  defined 
anatomically  as  an  aggregation  of  boils.  It  usually 
occurs  singly,  or  if  there  be  a  succession  of  them  they 
generally  affect  the  same  part. 

The  seat  of  election  is  the  hard  skin  of  the  nape  of 
the  neck,  and  the  back.  This  is  a  good  instance  of 
the  part  played  by  the  tissues  in  the  initiation  of  the 
morbid  processes  that  affect  them. 

Carbuncles  are  most  common  in  old  people,  and  in 
those  who  are  broken  down  by  visceral  disease;  hence 
it  is  a  concomitant  of  diabetes  and  kidney  affections. 

The  minute  anatomy  is  the  same  as  in  furuncle, 
but  the  inflammation  is  much  more  intense,  and 
liable  to  spread  widely  from  the  spot  primarily 
affected.  The  skin  is  intensely  congested  and  hard 
and  brawny  from  fibrinous  exudation.  A  number  of 
small  gangrenous  areas  make  their  appearance,  at  first 
dark,  but  afterwards  pale,  as  the  vessels  are  destroyed 
and  the  colouring  matter  of  the  blood  discharged,  and 
suppuration  is  established  around  them.  The  islets 
of  necrosed  tissue  come  away,  leaving  apertures 
through  which  pus  and  shreds  of  slough  make  their 
escape. 

Yery  often  wide  tracts  of  skin  become  gangrenous, 
or  are  lost  by  progressive  ulceration.  Whilst  the 
inflammation  is  subsiding  in  the  centre,  it  spreads  at 
the  periphery,  and  this  may  go  on  until  the  carbuncle 
has  attained  an  enormous  size.  There  is  very  little 
tendency  to  destruction  of  the  subjacent  muscles  and 
fasciae. 

The  general  symptoms  are  those  of  high   fever, 


78  Surgical  Pathology.  [Chap.  ix. 

intense  local  pain,  and  considerable  depression  of  the 
vital  powers. 

The  post-mortem  appearances  are  such  as  would 
be  found  after  any  severe  non-specific  inflammation. 
If  there  be  evidence  of  septic  infection  and  metastases, 
it  is  indicative  of  pyaemia  grafted  upon  the  primary 
disease. 

Malignant  facial  carbuncle.  —  This  is  a 
disease  which,  unlike  ordinary  carbuncle,  has  a  special 
tendency  to  attack  young  adults.  It  has  been  con- 
founded with  malignant  pustule  {q.v.),  but  it  differs 
from  it  in  its  being  marked  by  rapidly-progressive 
gangrene  and  purulent  infiltration,  in  the  greater 
liability  to  extensive  thrombosis  of  the  veins,  and  in  the 
absence  of  inoculation  from  a  known  specific  source. 

The  local  appearances  much  more  closely  resemble 
those  of  acute  farcy,  but  the  secondary  specific 
metastases  in  the  skin  (farcy-buds)  are  wanting,  and 
there  is  no  history  of  communication  of  the  disease  by 
glandered  horses. 

Malignant  carbuncle  usually  commences  in  the  lip, 
but  Billroth  records  a  case  where  it  began  in  a  scalp- 
wound,  and  Paget  one  in  the  back. 

The  skin  and  subjacent  structures  are  greatly 
swollen  and  congested,  the  vessels  are  thrombosed, 
and  this,  together  with  acute  exudation  and  decompo- 
sition, destroys  the  tissues  with  marvellous  rapidity. 
The  face  is  so  disfigured  that  the  •  features  are  un- 
recognisable. The  veins,  which  are  filled  with  clots, 
mark  the  course  of  suppurative  tracts. 

The  lymphatic  glands  are  swollen. 

There  are  all  the  signs  of  virulent  blood-poisoning. 
The  disease  is  extremely  fatal,  and  rarely  lasts  longer 
than  a  few  days. 

Malignant  pustule. — Synonyms,  "  contagious 
carbuncle,"  "anthrax."  In  the  sheep,  horse,  ox,  etc., 
it  is   known    as    "splenic    fever,"    "joint   murrain," 


Chap.'ix.]  Malignant  Pustule.  79 

"quarter  evil,"  and  "the  blood."  Malignant  pustule 
is  an  acute  specific  fever,  communicated  to  man  by- 
inoculation  with  the  wus  of  splenic  fever  of  cattle, 
etc.  The  contagion  consists  of  a  microscopical 
organism,  the  bacillus  anthracis  of  Cohn,  the  bacteri- 
dium  of  Davaine. 

The  chief  immediate  sources  of  contagion  are  the 
carcases,  hides,  wool,  and  hair  of  animals  that  have 
suffered  from  the  disease ;  hence  it  is  generally  met 
with  in  slaughterers,  tanners,  wool-sorters,  etc. 

The  term  "  malignant  pustule  "  is  a  misnomer,  for 
suppuration  is  conspicuous  by  its  absence.  The 
^'  pustule  "  first  appears  as  a  bright  red  papule  ;  upon 
this  a  vesicle  forms  and  bursts.  The  central  part  is 
then  converted  into  a  black  eschar  with  brawny 
cedematous  base,  which  becomes  surrounded  with  a 
crop  of  secondary  vesicles.  It  is  most  common  on 
the  face  and  hands.  It  spreads  deeply  rather  than 
superficially,  in  this  way  differing  from  carbuncle. . 

The  blood  coagulates  in  the  capillaries  from  accu- 
mulation of  the  bacillus  rods,  and  compression  from 
without  of  the  fibrinous  exudation ;  hence  the  cessa- 
tion of  the  circulation  and  the  gangrene. 

The  surrounding  tissues  are  congested  and  (Edema- 
tous. The  size  of  the  central  blackened  eschar  de- 
pends upon  the  duration  of  the  disease.  "It  may 
reach  the  size  of  a  shilling  "  (Greenfield),  The  lymph- 
glands  of  the  part  are  generally  enlarged. 

Besides  their  mechanical  effect  of  blocking  the 
vessels,  the  bacilli,  either  directly,  or  indirectly 
through  the  products  of  decomposition  which  they 
give  rise  to,  induce  symptoms  of  septic  intoxication. 

These  symptoms  vary  in  kind  and  degree.  The 
temperature  may  rise  to  104°  or  even  higher,  or  it 
may  be  subnormal.  The  general  blood-poisoning  is 
not  always  proportionate  to  the  intensity  of  the  local 
lesion.     In  severe  cases  the  condition  is  that  described 


8o  '    Surgical  Pathology.  [Cuap.  ix. 

by  Murchison  as  the  "  ty^Dlioid  state" — mental  de- 
pression, muttering  delirium,  brown  tongue,  muscular 
weakness,  etc. 

Post-mortem. — The  blood  is  found  more  or  less 
fluid,  dark,  and  sometimes  tarry.  The  intima  of  the 
vessels  is  stained  with  haemoglobin  set  free  by  destruc- 
tion of  the  red  corpuscles  during  life.  There  are  local 
congestions,  ecchymoses,  and  sometimes  more  diffuse 
extravasations,  and  more  rarely  wedge-shaped  infarc- 
tions, in  different  parts  of  the  body.  The  lungs  are 
congested,  as  is  also  the  mucous  membrane  of  the 
alimentary  canal.  There  are  often  subserous  and  sub- 
mucous petechias. 

History  of  the  micro  -  org^anism.  —  The 
bacillus  anthracis  consists  of  rods  varying  from  ^  s'^jpth 
to  T2Vo*^  ^^  ^^  \n.(^  in  length.  They  are  motionless, 
and  for  the  most  part  straight  or  sKghtly  curved. 
The  central  protoplasm  is  contained  in  a  denser  casing. 
The  rods  multiply  by  fission.  They  also  give  rise  to 
spores  by  differentiation  of  the  protoplasm,  and  these 
are  set  free  by  splitting  or  solution  of  the  encasing 
substance.  The  spores  grow  into  rods,  and  thus  the 
cycle  of  development  is  completed. 

The  spores  are  very  "tenacious  of  life;"  they 
survive  desiccation  and  subjection  to  very  high 
temperature  (100*^0.).  The  rods  are  destroyed  by 
putrid  decomposition,  and  by  exposure  to  much  lower 
heat  than  suffices  to  kill  the  spores. 

The  bacilli  can  be  cultivated  artificially  in  nitro- 
genous fluids,  in  the  presence  of  oxygen.  As  their 
development  advances  their  virulence  increases.  The 
disease  can  be  communicated  from  animal  to  animal 
ad  infinitum,  so  the  process  is  a  truly  infective  one. 

Other  forms  of  ttie  disease. 

1.  Malig^uaut  anthrax  oedema. —  Firm  gela- 
tinous oedema  is  met  with  in  various  parts,  especially 
the  eyelids.     The  typical  pustule  is  absent. 


Chap.  X.]  Hypertrophy.  8i 

2.  Internal  anthrax. —  There  is  no  primary 
lesion  of  the  skin.  The  poison  is  absorbed  by  the 
respiratory  or  alimentary  mucous  membrane.  The 
post-mortem  appearances  may  be  simply  those  of  acute 
blood-poisoning — anthracsemia.  More  commonly  there 
are  gross  changes  in  the  pulmonary  and  alimentary 
tracts  in  the  form  of  congestion,  thrombosis,  haemorr- 
hage, and  inflammation.  There  is  often  brawny 
oedema  of  the  cellular  tissue  of  the  neck,  and  enlarge- 
ment of  the  cervical,  mediastinal,  and  mesenteric 
glands. 


CHAPTER    X. 

HYPERTROPHY. 

Hypertrophy  may  be  simple  or  numerical,  accord- 
ing as  the  increase  in  bulk  is  due  to  a  simple  enlarge- 
ment of  pre-existing  elements  or  an  addition  to  their 
number.      Usually  the  two  are  combined. 

Hypertrophies  stand,  so  to  speak,  between  in- 
flammatory enlargements  and  the  new  formations ; 
but  were  an  attempt  made  to  sharply  define  and 
separate  them  from  these  groups  on  strict  pathological 
grounds,  a  number  of  cases  which  by  common  con- 
sent are  regarded  as  hypertrophies,  would  have  to  be 
excluded;  e.g.,  corns  and  the  bursse  found  beneath 
them,  thickened  bones,  enlarged  hairs  and  papillae 
around  chronic  ulcers,  enlarged  prostate,  etc. 

Hypertrophies  are  essentially  homopl^vstic ;  tumours 
are  frequently  heteroplastic. 

In  hypertrophy  proper  the  tissue  is  well  organised, 

and  there  is  a  corresponding  increase  in  vital  activity, 

whilst  in  inflammation  there  is  a  lowering  of  histo- 

logical  type  and  a  decrease  of  functional  power.      As 

G 


82  Surgical  Pathology.  [Chap.  x, 

a  rule,  the  increment  of  nutrition  is  preceded  by  a 
call  for  it,  "ubi  stimulus  ibi  affluxus ; "  but  now  and 
again  this  is  reversed. 

Hypertropliies  classified. — (1)  Spontaneous; 
(2)  compensatory  ;  (3)  irritative. 

The  spontaneous  comprise  certain  develop- 
mental and  anomalous  forms. 

In  developmental  hypertrophy  there  is  an  irre- 
gular evolution  as  regards  the  mode  and  extent  of 
growth. 

It  is  either  congenital,  as  when  a  child  is  born 
with  an  enlarged  hand  or  foot ;  or  it  comes  on  later  in 
life,  at  the  time  of  a  fresh  phase  of  developmental 
activity ;  e.g.,  a  general  hypertrophy  of  the  breast 
about  the  age  of  puberty  and  early  womanhood. 

Enlargement  of  the  prostate  in  old  men  may  be 
cited  as  an  anomalous  case,  there  being  no  satisfactory 
explanation  of  its  cause  ;  and  the  same  may  be  said  of 
enlargements  of  the  thyroid,  thymus,  and  tonsils. 

Compensatory  liypertropliies  are  for  the  pur- 
pose of  overcoming  increased  resistance,  or  for  sub- 
stituted action.  Thus  the  muscular  coat  of  the  bladder 
increases  in  bulk  that  it  may  cope  with  the  extra 
load  thrown  upon  it  by  a  stricture  of  the  urethra 
or  an  enlarged  prostate.  It  would  appear,  however, 
that  in  some  instances  hypertrophy  is  dependent 
simply  upon  increased  exercise  of  healthy  action, 
such  as  is  found  in  the  irritable  bladders  of  children, 
where  there  is  no  hindrance  to  the  escape  of  urine. 
The  heart,  gall  bladder,  intestine,  and  ureters  furnish 
examples  of  hypertrophy  from  obstruction  ct  /rente. 
Now,  since  a  continuous  or  frequently  recurring 
stimulus  is  necessary  to  this  form  of  hypertrophy, 
it  is  evident  why  the  involuntary  muscles  should 
exhibit  it  more  than  the  voluntary.  Voluntary 
muscles  (e.g.,  of  the  limbs)  increase  in  bulk  up  to  a 
certain  point  when  called  into  unwonted  action,  but 


Chap.  X.] 


Hyper  trophy. 


83 


beyond  this  they  tire,  and  then  the  repair  during  the 
shortened  intervals  of  rest  is  not  equal  to  the  loss  sus- 
tained by  over-exercise.  But  where  there  is  naturally 
more  or  less  continuous  action,  as  in  the  involuntary 


Fig.  2. — Hypertrophy  of  Bladder  from  Hydatid  Cyst  in  the  Pelvis. 
The  parasite  during  its  growth  irrital-ed  the  musctilar  coat  of  the 
bladder.  The  inflammatory  thickening  at  the  base  of  the  viscus 
caused  a  certain  amount  of  obstruction. 

o, Wall  of  Madder  seen  in  section;  6.  inner  surface  coarsely  fasciculated;  c> 
prostate  gland;  ti,  ureter;  e,  A'as  deferens ;/,  hydatid  cyst.  The  essential 
cysts  are  collapsed  and  folded  up  within  the  adventitious  cyst.  (Reduced 
one-half. 

muscles,  there  is  scarcely  any  limit  to  hypertrophy 
so  long  as  there  is  no  interference  with  the  supply 
of  properly  oxygenated  blood.  Thus  there  is  nothing 
to  show  that  thickening  of  the  muscular  coat  of  the 
intestine  above  a  stricture  ceases  of  itself  whilst  the 
resistance  continues. 


84  Surgical  Pathology.  [Chap.  x. 

The  same  holds  good  in  all  other  instances  where 
the  natural  stimulus  is  intermittent;  e.g.^  in  the 
glandular  organs,  such  as  the  testicles. 

If  one  kidney  be  crippled  or  destroyed  by  disease, 
the  other  undergoes  considerable  enlargement.  There 
is  undoubtedly  an  increase  in  the  size  of  the  tubules, 
but  whether  new  ones  are  formed  is  a  disputed  point. 
Paget  asserts  there  are. 

If  the  tibia  be  short  from  arrested  growth,  from 
injury  or  disease  of  the  epiphysis,  the  length  of  the 
limb  may  be  preserved  partially  or  entirely  by  an 
elongation  of  the  femur. 

Allied  to  these  forms  are  the  associated  hyper^ 
trophies,  where  the  changes  follow  others  in  parts 
intimately  connected  with  them;  e.g.,  eccentric  hyper- 
trophy of  the  bones  of  the  skull,  when  the  contents 
of  the  latter  are  increased,  and  concentric  when  they 
are  diminished.  The  thickening  in  these  cases  is  best 
seen  at  the  seat  of  the  original  centres  of  ossification. 

The  irritative  hypertrophies  are  caused  by 
intermittent  pressure,  for  continuous  pressure  leads 
to  atrophy.  Thus  the  papillae  become  enlarged,  and 
the  epidermis  is  thickened  in  the  form  of  corns  and 
callosities  ;  and  beneath  these  bursse  may  develop  to 
diffuse  the  abnormal  pressure  from  a  tight  shoe,  or 
that  misdirected  in  club  foot. 

In  all  cases  of  hypertrophy  there  is  an  increased 
supply  of  blood,  and  the  more  active  the  renewal 
the  more  nearly  do  the  new-formed  elements  con- 
form to  the  physiological  type.  Thus  in  the  preg- 
nant uterus  the  circulation  is  very  active,  and 
there  is  a  rapid  and  perfect  reproduction  of  in- 
voluntary muscular  fibres,  and  also  an  enlargement  of 
pre-existing  fibres  from  excessive  nutrition.  As  the 
necessity  for  the  hypertrophy  is  withdrawn  after 
delivery,  atrophy  sets  in ;  the  firm  contraction  of  the 
muscular  walls  itself  diminishing  the  blood  supply. 


Chap.  XL]  Atrophy.  85 

But  let  some  mechanical  cause  interfere  with  the 
natural  involution  of  the  uterus,  and  the  organ  will 
remain  enlarged  for  an  indefinite  period,  not  from  mere 
failure  of  the  atrophic  change  in  the  muscular  fibres, 
but  from  overgrowth  of  connective  tissue  (areolar 
hyperplasia),  the  result  of  mechanical  congestion. 

These  cases  show  how  a  chronic  inflammatory 
enlargement  may  overlap  and  simulate  a  triie  physio- 
logical hypertrophy ;  and  there  can  be  no  doubt  but 
that  the  latter  may  be  maintained  to  some  extent  by 
the  increment  of  nutrition  set  up  by  the  local  me- 
chanical hypersemia. 

When  the  original  stimulus,  instead  of  being 
physiological  and  simply  calling  for  increased  func- 
tional power,  is  an  artificial  one  (e.^.,  friction  against 
the  skin,  or  the  irritation  of  the  hair  follicles  and 
papillae  and  subjacent  bone  in  a  case  of  chronic  ulcer), 
the  plastic  exudation  is  not  all  used  up  in  fashioning 
tissues  after  the  likeness  of  the  normal  histological 
elements  of  the  part.  Some  at  least  pass  no  farther  from 
the  embryonic  type  than  indurated  connective  tissue. 

It  would  be  a  distinct  gain  if  the  word  hyper- 
trophy were  reserved  for  cases  where  there  is  a  call 
for  increased  functional  activity  and  compensation, 
and  the  term  irritative  overgroioth  employed  to  desig- 
nate those  arising  from  accidental  stimulation.     . 


CHAPTER    XI. 

ATROPHY. 


Development  and  growth ;  discharge  of  healthy 
function,  with  maintenance  and  repair;  and  finally 
a  decline  and  death,  make  up  the  sum  total  of  the  life- 
history  of  all  the  tissues.  The  wasting  of  old  age 
can  scarcely  be  looked  upon  as  evidence  of  disease ; 


86  Surgical  Pathology.  [Chap.  xi. 

but  it  rarely  happens  that  the  individual  passes 
through  his  existence  free  f;:om  abnormal  change. 
People  grow  old  before  their  time ;  some  in  one 
structure,  others  in  another. 

This  premature  agedness  may  show  itself  in 
blanching  and  loss  of  hair,  decay  of  teeth,  loss  of  the 
elastic  tread  of  youth,  senile  atrophy  of  the  brain,  or 
weak  and  fatty  heart. 

All  these  conditions  are  attended  with  a  diminution 
in  the  nutrition  of  the  tissues  whereby  their  proper 
constituents  lose  in  bulk  and  function. 

Atrophies  are  simple  or  essential,  or  secondary  to 
some  more  actively  destructive  process.  The  former 
we  see  in  the  arcus  senilis  and  degenerated  arteries 
of  the  aged,  the  latter  in  wasting  of  a  bone  by 
pressure  of  an  aneurism  or  its  interstitial  absorption 
by  inflammation,  cancer,  rickets,  or  mollities  ossiurn. 

Inflammatory  difiers  from  simple  atrophy  in  that 
it  is  often  followed  or  accompanied  by  constructive  or 
organising  changes.  Thus  osteophytes  are  almost 
always  found  in  the  neighbourhood  of  joints  destroyed 
by  caries. 

Causes  and  varieties  of  atrophy.  —  (1) 
Natural  or  physiological  atrophies  ;  e.g.,  of  the  uterus 
after  parturition,  of  the  breast  after  lactation,  of  the 
testicles  of  the  deer  after  the  rutting  season. 

To  these  may  be  added  the  spontaneous  withering 
of  the  thymus  and  the  thyroid  glands,  and  simple 
senile  wasting. 

(2)  A  part  may  waste  for  want  of  its  proper 
amount  of  functional  stimulus,  as  in  the  case  of 
paralysed  muscles,  of  the  optic  nerve  from  blindness, 
and  of  amputation  stumps. 

(The  natural  stimulus  to  the  nutrition  of  a  bone 
is  the  contraction  of  the  muscles  attached  to  it ;  and 
after  an  amputation  the  muscles  have  less  work  to  do.) 

(3)  Atrophies    of   nervous   origin. — The    loss    of 


Chap.  XL]  Atrophy.  "87 

nutrition  may  be  largely  influenced  by  disease  of  the 
nervous  system. 

The  secondary  descending  degenerations  of  the 
spinal  cord,  consequent  on  lesions  in  its  substance 
higher  up,  or  in  the  brain ;  the  wasting  of  the  distal 
portion  of  a  divided  nerve ;  and  the  absorption  of  the 
articular  ends  of  the  bones  in  locomotor  ataxia, 
are  instances  in  point. 

(4)  Partial  deprivation  of  hlood-sujoply,  as  when, 
in  fracture  of  the  shaft  of  a  long  bone,  the  nutrient 
artery  is  torn ;  or  the  brain  and  heart  soften  from 
obstruction  in  their  vessels. 

Then  there  are  numerous  instances  showing  the 
result  of  continuous  pressure.  Absorption  of  the  hard 
palate  by  a  badly  fitting  obturator ;  erosion  of  the 
vertebrae  by  an  aneurism  or  tumour  (Fig.  3)  ;  changes 
of  shape  of  the  ends  of  bones  in  unreduced  disloca- 
tions ;  the  ball-and-socket  pseudartbrosis  of  an  ununited 
fracture;  and,  lastly,  shrinking  of  the  testicle  from 
varicocele. 

(5)  Excessive  functional  activity  tells  its  tale  in 
the  form  of  atrophy  of  overworn  jaded  brains. 

The  waste  from  the  great  expenditure  of  nutritive 
force  is  not  repaired  for  want  of  the  natural  term 
of  rest. 

When,  exceeding  the  ratio  of  general  emaciation, 
the  heart  grows  smaller,  to  accommodate  itself  to  a 
diminished  amount  of  blood,  the  atrophy  is  called 
"purposive." 

This  is  sometimes  masked  by  a  relative  hyper- 
trophy, when  opposite  causes  are  at  work  in  the  same 
patient.  Thus  the  organ  may  retain  its  normal  weight, 
though  atrophied,  as  it  were,  from  the  wasting  of 
phthisis  or  cancer,  or  hypertrophied  from  the  obstruc- 
tion of  arterio-capillary  fibrosis  (Sibson.) 

Modes  of  atrophy. — The  process  may  work  out 
its    effect  by   a   simple   diminution  in  the   size,    and 


88  Surgical  Pathology.  [Chap.  xi. 

eventual  loss  in  number,  of  the  tissue  elements,  tliose 
that  remain  being  natural  in  appearance  and  con- 
sistence ;  e.g.^  the  fibres  of  striated  muscle.  But  more 
often  obvious  degenerative  changes  can  be  seen,  the 
chief  being  those  due  to  fatty  metamorphosis  and 
infiltration.  Muscles  that  have  lain  fallow  for  a  long 
time  from  paralysis,  or  from  forced  rest  in  joint 
disease,  as  a  rule  become  pale  and  soft.  The  bones 
which  in  the  latter  case  are  the  seat  of  interstitial 
absorption,  have  their  spaces  filled  with  fat,  and 
readily  fracture  when  attempts  are  made  to  break 
down  adhesions  in  the  articulations. 

Perhaps  the  best  example  of  fatty  atrophy  is  the 
arcus  senilis  of  the  cornea,  which  commences  in  a 
degeneration  of  the  stellate  corpuscles.  It  is  a  con- 
dition of  great  pathological  and  clinical  importance,  from 
its  frequent  association  with  wide-spread  vascular  decay. 

Probably  some  of  the  deaths  from  chloroform  are 
caused  by  acute  distention  of  the  degenerated  walls  of 
the  right  cavities  of  the  heart  during  the  struggling 
stage,  rather  than  by  the  direct  effect  of  the  poison. 

In  addition  to  fatty  transformation  of  the  proper 
elements,  the  connective  tissue  cells  become  loaded 
with  fat  from  infiltration ;  and  in  this  way  an  organ 
or  tissue  in  an  advanced  stage  of  essential  atrophy 
may  retain  or  exceed  its  normal  bulk ;  e.g.,  the  en- 
lai'ged  calves  in  pseudo-hypertrophic  paralysis. 

In  certain  structures  pigment  granules  are  de- 
posited. This  is  particularly  the  case  with  the  ganglion 
cells  of  the  nerve  centres  ;  e.g.,  those  in  the  anterior 
comua  of  the  grey  matter  of  the  spinal  cord  in 
infantile  paralysis. 

As  nutrition  fails  in  the  muscular  coat  of  the 
small  and  medium-sized  arteries,  in  the  rib  cartilages, 
and  in  many  other  situations,  the  parts  become  petrified 
with  lime  salts. 

Inflammatory  deposits    waste   by  a   fatty  and   a 


Chap.  XI.] 


Atrophy 


89 


mucoid  or  "  liquef active  degeneration."  The  latter 
change  is  best  observed  in  caries  of  bone.  There  the 
protoplasm  of  the  cells  becomes  fluid,  and  lactic  acid 
is  formed  (Cornil  and  Ranvier). 

Atrophy  of  Ibone. — That  continuous  pressure 
causes  atrophy,  and  intermittent  pressure  hypertroiDhy, 
are  sometimes  seen  in  the  same  preparation. 

In  the  museum,  of  St.  Mary's  hospital  there  is  a 
portion  of  the  dorsal  spine  in  which  the  vertebrae  have 


Pig.  3. — Vertebrae  absorbed  by  an  Aneurism. 
a.  Cancellous  ^0116  forming  floor  of  cavity  ;    6,  compact  hone  forming  floor  of 
cavity  ;  c,  new  bone  Ijy  which  the  vertebrae  are  anchylosed.  (Reduced  one-third). 

been  hollowed  out  by  an  aneurism  of  the  descending 
thoracic  aorta.    The  floor  of  the  cavity  is  quite  uniform. 


90  Surgical  Pathology.  [chap. xi. 

contrasting  with  the  irregularity  produced  by  caries 
or  cancer. 

On  the  right  side  these  vertebrae  have  become 
anchylosed  by  the  formation  of  a  considerable  amount 
of  new  bone  j  i.e.,  there  is  loss  of  substance  on  the 
left  side  and  central  portions  where  the  pressure  was 
constant,  whereas  the  right  margin,  which  was  sub- 
ject only  to  the  intermittent  pulsation  of  the  aneu- 
rismal  sac,  is  hypertrophied  (Fig.  3). 

According  to  Paget,  the  cancellous  tissue  is  not 
exposed  in  these  cases,  a  layer  of  compact  bone 
covering  the  surface.  The  specimen  in  question,  how- 
ever, shows  in  some  parts  the  open  fretwork  of  the 
interior  of  the  vertebrae,  though  not  so  plainly  as  in 
caries  or  cancer. 

The  modus  operandi  of  the  pressure  is  obvious 
— the  blood-vessels  of  the  adjacent  layer  are  com- 
pressed, and  the  bone  wastes  from  want  of  its  proper 
nutritive  supply. 

The  bones  in  old  age  undergo  a  rarefaction,  and 
the  earthy  salts  are  increased ;  hence  they  easily 
break.  Intracapsular  fracture  of  the  neck  of  the 
femur  from  slight  force  indirectly  applied  is  an  in- 
stance of  this.  The  atrophy  in  these  cases  is  eccentric. 
The  size  and  shape  of  the  bones  are  not  necessarily 
altered.  The  medullary  canal  is  enlarged.  In  eden- 
tulous jaws,  however,  the  alveolar  margin  is  absorbed, 
and  the  bones  are  in  every  way  smaller. 

Atropliy  of  muscle. — The  various  causes  of 
atrophy  are  well  illustrated  in  the  muscles,  voluntary 
and  involuntary,  plain  and  striped. 

Disuse  leads  to  wasting  of  the  muscular  coat  of 
the  bowel  below  an  artificial  anus. 

The  muscles  of  an  amputation  stump  gradually 
shrink  and  shorten  from  interstitial  atrophy,  and  not 
from  functional  contraction.  This  is  one  reason  why 
artificial  socket-limbs  are  not  ordered  for  some  months 


Chap.  XI.]  Atrophy.  91 

after  operation,  for  they  take  their  bearing  chiefly 
from  the  general  surface. 

If  the  flaps  are  too  short,  the  atrophic  shortening 
may  stretch  the  cicatrix  over  the  end  of  the  stump, 
and  cause  obstinate  ulceration. 

If  muscles  be  kept  habitually  shortened,  as  in 
flexion  and  adduction  of  the  thigh  from  hip-joint 
disease,  they  will  shrink.  This  may  ofier  a  serious 
bar  to  the  straightening  of  the  limb,  and  may  necessi- 
tate division  of  the  tendons. 

In  acute  inflammation  of  joints,  the  irritation  of 
the  articular  nerves  seems  reflexly  to  impair  the 
nutrition  of  the  associated  muscles,  and  to  lead  to  a 
wasting  out  of  proportion  to  the  disuse. 

Disease  of  the  motor  ganglion  cells  of  the  spinal 
cord  in  progressive  muscular  atrophy  and  in  infantile 
paralysis  causes  a  corresponding  wasting  of  the  muscles 
supplied  by  them. 

In  infantile  paralysis,  where  the  loss  of  power 
is  often  sudden  and  complete,  the  subsequent  wasting 
from  disuse  may  to  some  extent  be  averted  or  re- 
moved by  an  artificial  stimulus,  such  as  passive  move- 
ment or  electricity. 

When  there  is  advanced  general  fatty  degenera- 
tion of  the  muscular  system,  no  operation  should  be 
undertaken  that  is  not  absolutely  necessary,  for  the 
nutritive  activity,  which  is.  at  a  very  low  ebb,  would 
not  unlikely  fail  to  repair  an  extensive  wound. 

Atrophy  of  nerves. — In  addition  to  what  has 
been  already  said,  we  may  cite  softening  of  the 
brain  from  ligature  of  the  carotid,  embolism,  etc., 
degeneration  of  nerves  whose  function  has  been 
annulled  or  impaired;  e.^.,  in  amputation  stumps. 
According  to  Dickinson,  the  bulk  of  the  nerve  may  be 
retained  but  the  fibres  wasted,  fat  and  connective 
tissue  taking  their  place. 


92 


CHAPTER  XII. 

FATTY   INFILTRATION FATTY   DEGENERATION. 

Physiologically,  fat  exists  in  tlie  animal  tissues 
in  two  forms,  firstly,  in  combination  with  albuminoid 
constituents,  and  secondly,  in  tlie  free  state,  as 
granules  or  drOplets  in  the  cells.  In  like  manner  we 
find  it  in  pathological  states  either  as  a  mere  infiltra- 
tion, or  as  the  result  of  metamorphosis  of  cell  proto- 
plasm. 

Fatty  infiltration.— The  cells  of  the  liver,  and 
especially  those  forming  the  outer  zone  of  the  lobules, 
always  contain  a  certain  amount  of  fat,  elaborated  and 
stored  uj)  by  the  functional  and  nutritive  activity  of 
their  proto^^lasm.  This  is  notably  increased  during 
digestion.  The  excess  is  used  up  in  the  intervals  of 
feeding  to  supply  the  requirements  of  the  system,  both 
for  maintenance  and  repair. 

By  its  combustion  heat  is  given  off,  and  this  keeps 
up  the  normal  temperature,  and,  being  transmuted 
into  physical  force,  works  the  complicated  machinery 
of  the  body. 

The  villi  of  the  intestines  and  the  lacteals  are  also 
loaded  with  fat  during  digestion. 

Under  ordinary  conditions  the  balance  between 
waste  and  supply  is  maintained ;  but  this  may  be  lost 
on  either  side.  Thus,  if  the  amount  of  food  be  in- 
sufficient, fat  quickly  disappears  from  the  cells,  and 
the  animal  emaciates.  On  the  other  hand,  obesity  is 
the  consequence  of  overfeeding  and  inaction.  (The 
question  of  demand  and  supply  is  too  often  lost  sight 
of  in  the  treatment  of  patients  taken  from  active  life 
and  suddenly  confined  to  bed.  Apart  from  indiscre- 
tion in  diet,  such  a  condition  is  sufficient  in  itself  to 


Chap. xii.j  Fatty  Infiltration.  93 

cause  furred  tongue,  indigestion,  headache,  and  a  rise 
of  one  or  two  degrees  in  the  body  temperature. 
Hence  the  advantage  of  complete  rest  and  modified 
regimen  for  some  days  prior  to  the  performance  of 
any  severe  operation.) 

It  is  impossible  to  say  where  a  physiological 
becomes  a  pathological  adiposity,  but  certain  it  is  that 
the  secretory  function  of  an  orsan  may  be  strained  by 
excess  of  work,  just  as  much  as  a  muscle  used  beyond 
certain  limits  will  tire  and  waste. 

There  can  be  no  doubt  but  that  overfeeding  long- 
continued  is  a  cause  of  organic  disease  of  the  liver, 
and  this  again  of  the  whole  of  the  digestive  system. 
The  connection  between  the  "pleasures  of  the  table  " 
and  haemorrhoids  is  well  known. 

Although  fatty  degeneration  and  infiltration  are 
quite  distinct  processes,  they  are  not  uncommonly 
associated;  e.g.,  in  "fatty  heart"  the  muscular  fibres 
have  undergone  a  retrograde  change,  their  constituent 
fat  having  been  liberated.  At  the  same  time  a  con- 
siderable accumulation  of  fat  in  the  cells  of  the 
connective  tissue  beneath  the  pericardium  and 
between  the  muscular  fasciculi  is  far  from  rare. 
Again,  in  certain  paralytiG  states,  and  especially  in 
"  pseudo-hypertrophic  paralysis,"  the  muscles  are 
enlarged  in  the  gross  in  spite  of  the  wasting  from 
fatty  atrophy  of  their  fibres.  There  is  an  infiltration 
within  the  sarcolemma  and  between  the  muscular 
bundles. 

The  mere  disuse  of  a  part  is  often  followed  by  a 
marked  fatty  infiltration;  thus,  if  a  limb  be  kept 
fixed  for  a  long  time,  the  bones  become  rarefied  from 
simple  atrophy,  and  the  cells  in  the  enlarged  cancellous 
spaces  filled  with  fat.  A  similar  change  is  observed 
in  the  muscles.  The  bones  are  rendered  more  fragile, 
and  so  easily  break  on  applying  force  to  overcome 
stiffness  in  the  joints.    The  muscles  are  less  contractile, 


94  Surgical  Pathology.  [Chap.  xii. 

and  hence  amputation  flaps  retract  but  little,  and  their 
state  of  lowered  vitality  does  not  conduce  to  rapid 
healing. 

In  phthisis  a  noteworthy  feature  is  enlargement 
of  the  liver  from  fatty  infiltration.  The  reason  of 
this  is  not  clear.  It  may  be  from  the  impaired 
function  of  the  lungs,  but  it  must  not  be  forgotten 
that  high  temperature  leads  to  a  general  absorption 
of  adipose  tissue,  and  it  may  be  that  the  blood  thus 
overloaded  is  relieved  of  its  incubus  by  the  liver. 

•  Finally,  although  fatty  infiltration  may  mechani- 
cally impede  the  contraction  of  muscle,  and  hamper 
the  secretory  function  of  glands  such  as  the  liver,  it  is 
not  incompatible  with  the  continued  life  and  activity 
of  the  tissue  elements  affected. 

Fatty  deg:eiieratioii. — Here  there  is  a  true 
metamorphosis  of  the  cell  protoplasm.  By  some  it  is 
alleged  that  albuminoid  bodies  are  converted  directly 
into  fat,  but  it  is  more  probable  that  fat  normally 
exists  as  a  constituent  of  cell  composition  in  intimate 
combination  with  nitrogenous  substances. 

As  the  result  of  chemical  decomposition,  the 
constituent  fat  is  set  free,  and  appears  as  minute 
particles,  giving  a  granular  appearance  to  the  cells. 

Physiologically,  fatty  degeneration  occurs  in  the 
mamma,  and  the  sebaceous  and  ceruminous  glands. 
The  functional  activity  of  the  cells  involves  an  end 
to  their  vitality.  They  become  loaded  with  fat,  then 
disintegrate  and  set  free  their  contents.  In  the 
meantime  new  cells  replace  those  that  have  dis- 
appeared, and  so  the  balance  of  nutrition  of  the 
secreting  structures  is  maintained  as  long  as  sufficient 
pabulum  is  afforded,  and  the  secretion  is  carried  on 
within  natural  limits.  Over-action  leads  to  exhaustion 
and  wasting. 

During  the  involution  of  the  uterus  after  par- 
turition the  hyperfcrophied  muscular   fibres   undergo 


Chap.  XII.]  Fatty  Degeneration.  95 

retrograde  fatty  metamorphosis  prior  to  absorption ; 
and  the  same  happens  in  the  corpus  luteum  in  the 
ovary. 

In  old  age  fatty  degeneration  plays  an  important 
part  in  the  natural  decay  of  the  tissues.  Of  such 
nature  is  the  arcus  senilis  of  the  cornea.  As  a  rule, 
this  first  appears  in  the  upper  segment  as  a  dull, 
whitish  crescent,  at  a  short  distance  from  the  sclero- 
corneal  junction.  A  second  crescent  is  formed  below, 
and  these  two  extending,  the  circle  is  completed.  It 
is  of  little  clinical  importance  in  itself,  but  it  serves 
as  an  index  to  similar  changes  in  other  parts  of  the 
body,  and  particularly  the  vascular  system.  It  points 
to  the  likelihood  of  fatty  degeneration  of  the  heart 
and  arteries,  and  thus  to  the  dangers  of  syncope  and 
apoplexy. 

It  is  an  interesting  fact  that  in  an  eye  that  has 
been  the  seat  of  organic  disease,  even  though  all 
visible  signs  have  disappeared,  the  fatty  degeneration  of 
the  corneal  corpuscles  will  come  on  earlier  than  in  the 
pre\dously  sound  eye.  This  is  a  good  example  of  lowered 
vitality  constituting  a  "locus  resistentise  minoris." 

Another  instance  of  fatty  degeneration  and  natural 
decay  of  tissue  elements  is  seen  in  the  epithelioid  cells 
lining  the  large  arteries,  which  we  have  observed  in 
children  only  three  years  of  age  (Fig.  4,  a).  This,  and 
the  senile  changes  above  referred  to,  can  scarcely  be 
regarded  as  signs  of  disease.      (Vide  Atrophy.) 

At  the  same  time,  these  fatty  degenerations  from 
old  age  are  of  the  greatest  moment  in  the  consideration 
of  surgical  pathology,  bearing  so  directly  as  they  do 
upon  the  prognosis  of  disease,  and  the  repair  of 
wounds.  They  would  count  in  the  scale  against  the 
performance  of  operations  that  are  not  absolutely 
necessary. 

Causes  of  fatty  deg^eneration.  —  The  cir- 
cumstances   that  conduce  to  fatty  degeneration  are, 


g6  Surgical  Pathology.  [Chap.  xii. 

(1)  Inherent  disposition  to  decay;  (2)  defective  vas- 
cular supply;  (3)  rapid  growth;  (4)  high  temperature  ; 
(5)  the  action  of  poisons. 

There  may  be  a  combination  of  causes,  as  in 
inflammation  and  the  acute  fevers,  especially  those  of 
infective  origin  : 

(1)  This  was  discussed  when  speaking  of  true 
physiological  degenerations,  and  the  allied  changes 
dependent  on  old  age.  To  these  may  be  added 
cataract  of  the  crystalline  lens,  and  notably  the  fluid 
and  soft  varieties. 

(2)  There  are  several  ways  in  which  deficient 
sufply  of  hlood  entails  fatty  degeneration.  It  is 
seen  in  its  simplest  form  in  diseases  that  diminish  the 
elasticity  and  lessen  the  calibre  of  the  arteries,  either 
by  a  primary  calcification  of  the  middle  coat,  or 
thickening  and    irregularity  from    chronic    and    sub- 

.  acute  arteritis.  This  is  well  illustrated  in  the  heart. 
At  times  the  orifices  of  the  coronary  arteries  are 
greatly  narrowed  from  atheroma  of  the  first  part  of 
the  aorta ;  more  frequently  the  walls  of  the  arteries 
themselves  are  extensively  afiected  as  well.  Anaemia  (in 
its  physiological  sense)  over  wide  tracts  follows  obstruc- 
tion from  embolism  and  thrombosis  and  their  conse- 
quent infarctions,  the  extent  of  it  depending  upon  the 
freedom  of  the  collateral  circulation.  In  the  brain, 
where  this  is  very  limited,  softening  is  sure  to  ensue 
if  a  vessel  of  considerable  size  be  blocked.  Althous^h 
three  varieties  of  cerebral  softening  are  described 
{red,  yellow,  and  white),  there  are  two  factors  only 
that  contribute  to  the  result  :  firstly,  the  suddenness 
and  completeness  of  arrest  of  the  blood  stream ;  and 
secondly,  by  implication,  the  amount  of  blood  in  the 
part.  In  all  three  there  is  fatty  degeneration  of  the 
brain  substance  and  of  the  products  of  exudation. 
If  a  good-sized  vessel  be  plugged  by  an  embolus,  the 
venous  reflux  and  capillary  stagnation  and  rupture 


Chap.  XII.]  Fatty  Degeneration.  97 

reach  their  limit.  The  colouring  matter  of  the  dis- 
integrating infarct  mingles  with  the  fatty  debris,  and 
a  semi-diffluent  red  pulp  obtains.  If,  on  the  other 
hand,  the  arrest  be  gradual,  there  will  be  sufficient 
force  to  drive  the  blood  through  the  obstructed 
artery  and  its  capillaries  and  veins  beyond  ;  but  the 
current  will  be  slow  and  small,  and  inadequate  to  the 
maintenance  of  the  tissue  it  supplies,  which  will 
consequently  waste  from  fatty  atrophy.  Between 
the  red  and  the  white  softening  stands  the  yellow,  but 
it  represents  only  one  shade  out  of  the  many  passing 
from  white  to  red. 

At  times  a  steady  degeneration  goes  on  for  a 
period,  giving  rise  to  white  softening,  and  this  is 
subsequently  modified  by  capillary  rupture  at  the 
margin. 

Fatty  degeneration  of  the  heart  and  atheroma 
of  the  cerebral  arteries  are  the  precursors  of  white 
softening ;  sudden  occlusion  by  embolism  or  throm- 
bosis, of  red. 

Cerebral  softening  is  never  sharply  defined,  but 
passes  gradually  into  the  surrounding  healthy  brain 
substance. 

Under  the  microscope,  there  will  be  observed,  in 
variable  quantity  according  to  the  kind  of  softening, 
blood  corpuscles,  pigment  granules  and  crystals,  large 
compound  granule  cells,  free  fat  particles,  crystals  of 
fatty  acids,  and  cholesterine,  and,  if  the  process  have 
been  rapid,  shreds  or  sloughs  of  brain  tissue. 

Fatty  degeneration  is  a  constant  feature  in  all 
infianfimatory  exudations.  It  is  chiefly  due  to  the 
insufficiency  of  blood  supply  from  the  tension  on  the 
capillaries  ;  but  the  increased  temperature  of  the  blood 
in  general,  and  of  the  inflamed  part  in  particular,  and 
probably  also  the  deleterious  effect  of  the  chemical 
products  of  decomposition  of  the  exudation,  have 
much  to  do  with  it.      It  involves  not  only  the  pus 

H 


pS  Surgical  Pathology.  [Chap.  xii. 

corpuscles,  but  the  walls  of  the  blood-vessels,  and,  in 
fact,  all  the  elements  that  make  up  the  inflamed  tissue. 

(3)  In  rapidly  growing  tumours^  such  as  cancers 
and  sarcomas,  fatty  degeneration  often  reaches  such  a 
degree  that  large  tracts  break  down  into  a  diffluent 
pulp,  constituting  "softening  cysts."  There  are  two 
reasons  for  this  extensive  fatty  change :  1st,  the 
formation  of  blood-vessels  cannot  keep  pace  with  the 
growth  of  the  tumour,  and^  from  the  softness  of 
the  latter,  capillary  ruptures  are  common ;  and  2nd, 
the  vital  activity  of  the  cells  is  expended  in  their 
multiplication,  to  the  exclusion  of  a  higher  develop- 
ment, hence,  being  unstable,  they  wither  and  die. 

(4)  Hyperpyrcexia  is  a  powerful  cause  of  fatty 
degeneration,  and  cannot  well  be  overrated,  whether 
it  be  considered  from  a  pathological  standpoint,  or  in 
its  practical  application  to  the  treatment  of  disease. 
Post  mortem  all  the  organs  are  found  softened,  and 
break  down  readily  under  the  finger.  They  feel  greasy, 
and  are  of  a  dirty  yellow  colour. 

The  rapid  transformation  of  protoplasm  into  fat 
explains  the  danger  of  fatal  syncope  from  intrinsic 
failure  of  the  heart. 

The  beneficial  efiect  of  bringing  down  the  tempera- 
ture by  the  cold  bath,  or  large  doses  of  certain  drugs, 
such  as  quinine,  is  very  marked.  The  heart  acts  more 
powerfully,  and  the  pulse  becomes  slower,  and  head- 
ache and  delirium  are  decidedly  checked. 

(5)  The  action  of  poisons. — Poisons  causing  fatty 
degeneration  naturally  fall  into  two  groups  : — 

(a)  The  materies  morbi  of  infective  fevers,  in- 
cluding the  acute  specifics,  and  septicaemia. 

(h)  Certain  mineral  poisons.  The  chief  of  these 
is  phosphorus,  then  come  antimony,  arsenic,  and 
mercury. 

How  they  act  is  uncertain.  It  may  be  that  they 
diminish   or  destroy  the  vitality  of  the  tissues,   and 


Chap.  XII.l 


Fatty  Degeneration. 


99 


that  these,  no  longer  restrained  by  the  conditions  of 
life,  fall  a  prey  to  chemical  decomposition,  of  which 


Fig.  4. 

A,  Eatty  defeneration  of  the  tunica  interna  in  a  flake  of  this  membrane.    In  the 

midst  of  the  flbrillated  tissue,  b,  are  seen  masses  of  fat  granules,  a,  resulting 
from  the  fatty  degeneration  of  the  flat  ramifying  cells  of  this  layer  (x  200). 

B,  Secondary   products   of  fatty  degeneration;   a,  plates  of  cholesterine ;   6, 
crystals  of  stearic  acid  (Cornil  and  Ranvier). 

fat  is  the  chief  product.  That  death  is  the  cause,  and 
not  the  consequence,  of  fatty  degeneration,  is  supported 
by  the  fact  that  when  dead  bodies  are  allowed  to 
decompose   slowly,   under  the   influence   of  moisture, 


100  Surgical  Pathology.  [Chap.  xiii. 

ordinary  putrefaction  is  arrested,  and  the  tissues  are 
converted  into  a  fatty  body  termed  adipocere. 

Microscopy  and  chemistry  of  fatty  degene- 
ration.— Fat  granules  appear  first  around  the  nuclei 
of  the  cells.  This  can  be  easily  observed  in  muscle, 
where  the  nuclei  are  large  and  elongated.  The  fat 
particles  are  here  deposited  in  parallel  streaks.  They 
are  very  numerous,  dark,  and  highly  refractive.  The 
smaller  ones  merge,  but  the  cell  is  not  distended  by  a 
large  drop,  as  in  fatty  infiltration.  After  the  cells 
break  up  the  granules  are  dispersed,  and  are  then  more 
readily  absorbed.  Absorption  is  extensive  and  very 
constant,  and  hence  it  is  not  surprising  that  fatty 
degeneration  is  the  principal  mode  of  atrophy.  If  the 
fat  be  in  large  amount,  or  long  retained,  it  breaks  up 
into  the  fatty  acids  and  cholesterine.  Stearic  acid 
crystals  are  rhomboidal,  acicular,  and  stellate. 
Cholesterine  appears  as  plates,  with  pieces  chipped 
out  of  the  corners  (Fig.  4). 

Fat  granules  are  dissolved  by  ether  and  strong 
solution  of  caustic  alkali ;  they  are  turned  black  by 
osmic  acid,  but  do  not  take  the  staining  from  logwood 
or  carmine.  If  iodine  be  added  to  cholesterine,  and 
then  strong  sulphuric  acid,  a  blue  colour  is  obtained. 
Sulphuric  acid  alone  gives  a  deep  red  colour. 


CHAPTEU    XIII. 

MUCOID    AND    COLLOID    DEGENERATION. 

These  changes  are  very  closely  allied,  and  are 
found  under  similar  circumstances.  It  is  difficult, 
without  the  aid  of  chemical  reagents,  to  distinguish 
between  them. 

Mucoid  deg:eneration. — This  alteration  in  the 


Chap.  XIII.]        Mucoid  Degeneration.  ioi 

composition  of  the  tissues  does  not  appear  to  depend, 
like  fatty  degeneration,  upon  a  mere  diminution  in 
nutritive  supply,  but  to  be  an  essential  factor  in  the 
life-history  of  many  new  growths  and  other  morbid 
products. 

Physiologically.,  mucoid  tissue  is  widely  distributed 
in  the  fcetus,  where  it  marks  the  transitional  stage 
from  embryonic  to  more  fully  developed  structures, 
and  particularly  connective  tissue.  In  the  mucous 
membranes  the  transformation  of  the  protoplasm  of 
the  epithelial  cells  into  mucin  constitutes  the  natural 
secretion. 

In  the  main,  the  cells  are  destroyed  by  the  pro- 
cess, and  are  replaced  by  others  formed  beneath  them  ; 
but  it  seems  probable  that  a  dehiscence  or  discharge 
of  their  contents  may  occur  without  a  necessary 
loss  of  vitality.  Mucous  tissue  is  permanent  in  the 
Whartonian  jelly  of  the  umbilical  cord,  and  in  the 
vitreous  humour  of  the  eye. 

Pathogeny. — In  the  majority  of  cases  this  form 
of  degeneration  is  found  either  in  tissues,  where  it  is  a 
physiological  constant,  or  in  those  that  are  but  little 
removed  from  the  embryonic  type.  In  inflammation 
of  the  mucous  membranes  there  is  an  exaggerated 
secretion.  We  see  evidence  of  this  in  the  flux  of 
nasal  catarrh,  and  in  the  ropy  mucus  from  an  inflamed 
bladder. 

It  may  be  stated  that  anything  which  tends  to 
render  the  vitality  of  the  tissues  unstable  tends  also 
to  the  formation  of  mucin  in  the  cells  and  intercellular 
substance.  Hence  it  is  far  from  rare  in  inflammatory 
products  and  new  growths.  Tumours  that  spring 
from  the  mucous  membranes  are  commonly  gelatinous ; 
e.g.,  the  simple  polypi  of  the  posterior  nares.  In 
them  the  mucoid  transformation  goes  on  ^^aH  fassib 
with  the  increase  of  tissue,  so  that  there  is  a  uniform 
glistening  throughout.      Growths  of  similar  structure 


I02 


Surgical  Pathology. 


[Chap.  XIII. 


are  found  springing  from  connective  tissue  in  various 
situations — beneath  the  skin  and  fasciae,  and  in  the 
parenchyma  of  organs,  the  parotid  gland,  for  example. 
There  are  some  tumours  in  which  the  mucoid 
change    is    not   generally   diffused,    but    scattered    in 


Fig.  5. — Multiple  Cystic  Epithelioma  of  Lower  Jaw ;  Cyst  Develop- 
ment in  process. 

Ac  a,  the  central  round  epithelial  cells  are  undergoing  distension  from  mucoid 
metamorphosis  •  at  h  and  c,  this  is  further  advanced ;  at  d,  all  the  central 
cells  of  the  loculi  have  disappeared.  The  peripheral  columnar  cells  remain 
as  an  epithelial  lining  to  the  cysts,  e,  interlobular  tissue,  composed  for  the 
most  part  of  spindle-shaped  cells  ;  in  other  parts  of  the  growth  they  had 
developed  into  fibrous  tissue. 


patches  as  a  secondary  degeneration  and  softening. 
By  the  fusion  of  contiguous  droplets  cysts  are  formed, 
the  walls  of  which  are  smooth  or  rugged,  and  the 
contents  semifluid,  and  either  clear  or  turbid,  colour- 
less or  stained.  If  coloured  or  turbid,  it  is  due  to 
admixture  with  granular  fatty  matter  or  blood  pig- 
ment, and  not  to  alteration  in  the  chemical  composition 
of  mucin  (Fig,  5). 


Chap.  XIII.]        Mucoid  Degeneration.  103 

Of  this  nature  are  many  cystic  sarcomata  and  en- 
chondromata. 

The  costal  and  articular  cartilages  and  the  inter- 
vebral  discs  are  liable  to  undergo  this  form  of  de- 
generation. It  is  seen  in  the  rib  cartilages  of  old 
people,  in  joints  affected  by  "white  swelling,"  and  in 
the  spinal  column,  the  seat  of  caries. 

The  glairy  discharge  and  gelatinous  granulations 
of  many  ulcers  are  explained  in  the  same  way. 

It  is  said  that  in  mucoid  degeneration  the  inter- 
cellular substance  is  attacked  in  preference  to  the 
cells,  the  reverse  of  colloid  degeneration. 

The  existence  and  general  distribution  of  mucoid 
degeneration  rest  upon  a  physiological  basis ;  but 
there  seems  to  be  no  satisfactory  explanation  why 
gelatinous  polypi  should  be  common  in  the  nose  and 
i^re  in  the  rectum  and  bladder,  nor  why  some  growths 
sliould  be  riddled  with  mucous  cysts  whilst  others  of 
like  structure  remain  free. 

Microscopy. — The  fibres  of  connective  tissue 
swell  up,  and  their  outline  becomes  obscured  and 
finally  lost.  Elastic  tissue  resists  the  change  much 
better  than  the  white  variety.  When  the  cells  are 
affected,  a  drop  of  mucin  appears  in  the  protoplasm 
(Fig.  5,  6).  It  enlarges  and  pushes  the  nucleus  to 
one  side.  Eventually  all  signs  of  cell  wall  and 
nucleus  disa,ppear.  In  the  myxomata  and  in  the 
umbilical  cord,  the  outrunners  of  the  branched  cells 
unite  to  form  a  delicate  network,  spun,  as  it  were, 
through  the  homogeneous  gelatinous  matrix.  [Vide 
Figs.  61,  b,  62,  b.) 

The  secretion  from  inflamed  mucous  membranes 
contains  granular  cells,  probably  leucocytes. 

Chemistry. — Mucin  is  only  found  in  alkaline 
fluids.  It  is  precipitated  by  alcohol,  alum,  and  dilute 
mineral  and  acetic  acids.  The  precipitate  redissolves 
in  excess  of  mineral  acid,  but  this  is  not  the  case  with 


I04  Surgical  Pathology.  rchap. xiir. 

acetic.      It   swells  up    in  water,   but   is   not   soluble 
in  it. 

Mucin  reduces  cupric  sulphate.  It  is  converted 
into  acid- albumin  by  the  mineral  acids. 

Though  closely  allied  to  albumin,  it  differs  from 
it  in  not  being  precipitated  by  bichloride  of  mercury, 
tannin,  nor  by  boiling  j  and  in  the  absence  of  sulphur 
from  its  composition. 

Its  congeners^  gelatine  and  chondrin,  contain  a 
small  percentage  of  sulphur,  and  are  precipitated  by 
alum  and  mercuric  chloride.  Mucin  may  be  con- 
sidered as  the  chemical  product  of  the  retrograde 
metamorphosis  of  these  bodies,  a  reversion  to  the 
embryonic  state. 

Colloid  de§-eiieratioii  is  closely  related  to 
mucoid.  It  affects  chiefly  the  cells,  but  the  inter- 
cellular substance  is  not  exempt.  Physiologically  it 
is  sometimes  met  with  in  the  thyroid  gland,  even  in 
very  young  children. 

It  is  conspicuous  in  many  cases  of  bronchocela 
In  them  the  change  may  be  confined  to  individual 
glandular  acini ;  but  very  commonly,  by  the  coalescence 
of  the  latter,  cysts  are  formed,  which  contain  a  semi- 
gelatinous  colourless  or  yellow  fluid.  It  gives  the 
characteristic  appearance  to  colloid  cancer,  which  has 
a  special  tendency  to  affect  the  intestines,  omentum, 
and  ovaries.  We  have  also  observed  this  variety  of 
malignant  disease  in  the  breast  and  spermatic  cord. 

It  is  found  in  other  growths ;  e.^.,  the  sarcomata 
and  enchondromata. 

The  essential  structure  of  tumours  is  not  altered 
by  its  presence,  though  it  modifies  their  physical  and 
chemical  characters. 

The  colloid  material  is  not  precipitated  by  alcohol ; 
mucin  is. 

Zeiakerism.— This  term  has  been  applied  to  a 
peculiar    form    of    degeneration,     allied    to    colloid. 


Chap. XIII.]        Colloid  Degeneration.  105 

described  by  Zenker  as  occurring  in  tbe  voluntary 
muscles  in  typhoid  fever ,  notably  the  adductors  of  the 
thigh,  the  diaphragm,  and  abdominal  recti. 

It  has  been  observed  in  other  febrile  disorders. 
Cornil  and  Ranvier  met  with  a  similar  condition  in 
the  muscles  around  centres  of  inflammation  and  new 
growths.  It  has  also  been  detected  post  mortem  in 
muscles  that  had  undergone  injury  during  life.  Whether 
it  be  a  distinct  and  peculiar  form  of  degeneration,  or, 
as  Cohnheim  supposes,  a  modification  of  post-mortem 
coagulation  of  myosin,  is  not  certain. 

The  fibres  affected  necessarily  lose  their  contrac- 
tility, and  become  soft.  From  want  of  support  the 
blood  capillaries  may  rupture,  the  resulting  haemorr- 
hages causing  pain  and  tenderness,  and  even  swelling 
along  the  course  of  the  muscles. 

Microscopy. — The  alteration  in  structure  is  by 
no  means  general  in  the  same  muscle.  Patches  appear 
here  and  there  in  the  midst  of  what  looks  like  healthy 
tissue.  Even  individual  fibres  can  be  seen  lying  side 
by  side  with  others  that  have  entirely  escaped,  re- 
minding one  of  the  partial  distribution  of  lardaceous 
degeneration  in  the  muscle  cells  of  the  blood- 
vessels. 

The  fibres  affected  are  greatly  swollen.  They  look 
glistening,  having  lost  their  natural  striation.  The 
sarcolemma  is  wrinkled  irregularly  from  transverse 
cleavage  of  its  contents. 

Regeneration  takes  place  by  absorption  of  the 
diseased  fibres  and  the  development  of  new  ones. 

Myxcedema. —  In  this  disease  the  connective 
tissue,  especially  of  the  hands,  feet,  and  face,  becomes 
swollen.  Its  constituent  gelatine  and  chondrin  un- 
dergo a  chemical  reversion  to  the  embryonic  condition, 
being  converted  into  mucin. 

There  may  or  may  not  be  disease  of  the  kidneys. 
The  disease  is  slowly  progressive,   and    the  patients 


io6  Surgical  Pathology.  [Chap.  xiv. 

evince  a  dullness  of  intellect  and  gradual  diminution 
of  bodily  vigour.  Tiie  etiology  is  involved  in  ob- 
scurity. 


CHAPTER  XIY. 

PIGMENTATION PIGMENTARY    DEGENERATION. 

The  term  pigmentation  is  of  wider  application 
tban  pigmentary  degeneration.  It  is  true  there  is 
a  tendency  to  the  deposit  of  pigment  in  structures 
that  are  losing  their  vitality;  but  there  are  many 
instances  that  do  not  fall  under  this  category ;  such, 
e.g.,  are  the  melanotic  tumours,  in  which  the  process 
of  fixation  and  storage  of  colouring  matter  is  as  much 
an  essential  part  of  the  life-history  of  these  growths 
as  the  formation  and  arrangement  of  the  tissue 
elements  that  compose  them. 

False  pig-mentation. — In  the  first  place,  a  dis- 
tinction should  be  drawn  between  true  and  false  pig- 
ments, or  rather,  between  those  that  are  derived  from 
the  blood  (primarily  or  secondarily)  and  those  that 
are  introduced  from  without.  Of  the  latter  the  most 
common  form  is  carbon  suspended  in  the  air  in  the 
form  of  minute  particles.  These  are  carried  to  the 
respiratory  mucous  membrane,  to  which  they  adhere. 
Eventually  they  becjome  fixed  in  the  pulmonary  tissue, 
partly  by  their  mechanical  action,  and  partly  by  the 
agency  of  the  protoplasm  of  the  cells,  in  the  same  way 
that  granules  are  appropriated  by  amoebae  from  the 
fluids  in  which  they  live. 

Not  only  do  these  particles  invade  the  parenchyma 
of  the  lungs,  but  they  find  their  way  into  the 
lymphatics,  and  are  arrested  in  the  bronchial  and 
mediastinal  glands.     Such  accidental  pigmentation  is 


Chap.  XIV.]  Pigmentation,  107 

well  exemplified  in  (1)  tlie  lungs  of  miners,  which  are 
very  liable  to  be  ajBfected  with  a  form  of  fibroid 
phthisis,  the  overgrowth  of  connective  tissue  being 
due  to  the  irritating  action  of  the  sharp  angular  pieces 
of  carbon  inhaled. 

(2)  Lead  workers  and  others  who  are  the  sub- 
jects of  chronic  poisoning  by  the  metal,  show  a  hlue 
line  in  the  gums.  Here  the  lead  is  probably  deposited 
in  combination  with  the  albuminoid  constituents  of 
the  tissues,  although  it  is  supposed  by  some  that  it 
takes  the  form  of  sulphide,  sulphuretted  hydrogen 
evolved  from  the  decomposition  about  the  teeth  com- 
bining with  a  soluble  salt  of  the  metal  carried  by  the 
capillaries. 

(3)  Of  like  nature  is  the  occasional  discoloration 
of  the  skin  from  long-continued  internal  use  of  silver 
nitrate. 

(4)  From  tattooing  and  gunpowder  explosions.  We 
have  a  good  instance  of  the  former  in  the  intentional 
pigmentation  of  the  cornea  for  the  purpose  of  hiding 
the  unseemly  appearance  of  indelible  scars  (leucomata). 

True  pigmentation  consists  of  the  liberation 
of  the  colouring  matter  of  the  red  blood-corpuscles, 
and  its  fixation  by  the  tissues  in  the  granular  or 
crystalline  form,  not  as  haemoglobin^  but  as  some 
derivative,  the  product  of  chemical  decomposition. 
The  pigment  may  be  derived  directly  from  the  blood, 
or  through  the  medium  of  some  natural  secretion  as 
the  hile  or  urine.  There  are  certain  tissues  of  the 
body  of  which  it  is  a  natural  constituent.  Such  are 
the  skin,  choroid  coat  of  the  eye,  liver,  spleen,  muscle, 
and  nerve  cells. 

Physiologically,  it  is  temporarily  increased  in  the 
skin  from  sunburn  and  pregnancy;  and  standing 
midway,  as  it  were,  between  physiological  and 
pathological  pigmentation  is  the  mottling  of  the  skin 
in  freckles,  and  the  melanosis  of  congenital  moles. 


io8  Surgical  Pathology.  [Chap.  xiv. 

In  whatever  tissues  pigment  naturally  exists,  there 
will  it  appear  in  excess  in  most  morbid  changes  that 
affect  them,  even  though  the  immediate  seat  of  the 
disease  become  paler  than  normal ;  e.^.,  the  effect  of 
choroiditis  is  often  to  leave  whitish  patches  surrounded 
by  dense  black  irregular  zones. 

Cicatrices  of  the  skin  would  at  first  sight  appear 
an  exception  to  this  rule,  but  as  a  matter  of  fact  they 
support  it,  the  issue  mainly  turning  upon  the  point 
whether  the  rete  be  entirely  destroyed  or  no,  for  the 
rete  is  the  natural  seat  of  the  cutaneous  pigment. 

8oiu'ces  of  true  pigmeutatioii  and  stain- 
ing. 

1.  The  hile. — In  jaundice  the  conjunctiva,  skin, 
and  urine  show  the  characteristic  colour,  and  so  do 
coincidental  inflammatory  exudations,  such  as  pneu- 
monic sputa. 

In  these  cases  it  is  more  a  staining  than  real 
pigmentation,  for  the  bile  pigment  is  in.  the  liquid 
state,  and  is  quickly  reabsorbed  when  the  cause  of  the 
jaundice  is  removed. 

In  gall  stones  pigment  is  always  present.  It  varies 
much  as  to  colour  and  amount,  and  somewhat  as  to 
composition. 

2.  The  urine. — The  colouring  matter  of  the  urine 
gives  the  "  cayenne  pepper "  appearance  to  gravel, 
and  the  pink  colour  to  deposits  of  urate  of  soda. 
Urinary  calculi,  again,  have  different  hues  indicative 
or  suggestive  of  their  composition ;  e.g.,  the  brown 
and  fawn  colour  of  uric  acid ;  and  the  yellow  of  cystic 
oxide  (changing  to  green  on  long  exposure). 

3.  The  blood,  however,  is  the  chief  immediate 
source.  The  pigment  is  either  extracted  and  stored 
Lip  by  the  activity  of  living  cells  without  any  lesion  of 
blood-vessels,  as  in  melanotic  growths,  or  it  is  the 
remains  of  extravasation  or  thrombosis.  In  both 
cases  the  haemoglobin  as  set  free  from  the  corpuscles 


Chap.  XIV.] 


Pigment  A  tion. 


109 


is  in  solution;  it  afterwards  undergoes  chemical 
decomposition,  and  this  furnishes  the  variation  in 
tint  seen;  e.g.,  in  an  ordinary  bruise.  It  does  not 
remain  diffused  for  long,  but  assumes  the  granular  or 
crystalline  form.  The  colour  of  the  granules  may  be 
yellow,  orange,  dark  brown,  or  black,  and  no  doubt 
the  composition  varies  accordingly.  There  is  no 
proof  that  any  definite  compound,  which  has  been 
described  under  the  name  of  melanin^  has  any  real 


»|f  t*'^!>- 


J^.     T:  ^-.  # 


'^m^ 


••i«v'-^ 


B 


Fig.  6, — A,  Melanotic  Sarcoma  of  Muscle ;  b,  Granular  and  Crystalline 
Pigment  from  a  case  of  old  Cerebral  Hsemorrliage. 

existence ;  the  dense  black  pigment  so  termed  is  one 
of  the  last  products  of  a  series  of  chemical  changes. 
It  does  not  necessarily  follow,  however,  that  change 
of  colour  always  implies  a  change  in  composition- 

The  greater  part  of  the  colouring  matter  of  blood 
clots  is  absorbed  by  the  vessels,  and  the  extent  of 
absorption  depends  upon  the  freedom  of  the  circula- 
tion; hence,  in  the  brain  (Fig.  6,  b),  where  anastomoses 
are  scanty,  we  meet  with  permanent  deposits  of 
pigment,  and  the  crystalline  variety  is  more  common 
in  this  situation  than  elsewhere.  We  have  seen  these 
crystals  in  the  fluid  of  hydrocele,  in  ovarian  cysts,  and 
in  the  debris  of  liver  tissue  in  acute  yellow  atrophy. 
It  is  noteworthy  that  granules  and  crystals  are  some- 
times found  in  vessels  that  have  been  blocked  by  coagula. 


no  Surgical  Pathology.  [Chap.  xiv. 

Apart  from  antecedent  extravasation  or  thrombosis, 
pigmentation  occurs  {a)  as  an  essential  feature  of 
some  1WW  growths  (Fig.  6,  a),  especially  sarcoma  of 
the  choroid  and  skin.  We  know  that  sarcomas  are 
based  upon  the  type  of  embryonic  or  developmental 
tissue,  and  that  nutritive  changes  occur  in  them  in 
greater  variety  than  in  other  new  formations,  Cancers 
are  much  less  liable  to  pigmentation  than  sarcomas. 
Encephaloid  takes  the  lead,  there  'being  comparative 
immunity  in  scirrhus  and  epithelioma.  Pigmenta- 
tion is  not  confined  to  malignant  growths,  for  it  is 
far  from  rare  in  warty  excrescences  of  the  skin. 
In  any  case,  the  presence  of  pigment  marks  only  a 
nutritive  modification  in  the  elements  of  a  tumour, 
and  has  no  direct  reference  to  structural  pecu- 
liarity as  suggested  by  the  expression  melanoma. 
Melanotic  growths,  like  natural  pigment,  are  more 
widely  distributed  in  the  lower  animals  than  in  the 
human  subject.  As  would  be  expected,  the  granules 
are  for  the  most  part  contained  within  the  cells  of  the 
growth,  but  some  are  found,  both  scattered  and 
aggregated,  in  the  intercellular  substance.  It  is  more 
than  likely,  however,  that  many  of  these  collections 
were  originally  intracellular,  and  that  they  were  left 
in  situ  after  the  atrophy  and  disappearance  of  the 
cells  that  held  them. 

(h)  In  long-standing  passive  congestions  pigmenta- 
tion is  very  constant,  whether  it  has  its  origin  in 
thrombosis,  or  capillary  extravasation,  or  the  escape  of 
blood-corpuscleswithout  recognisable  rupture  of  vessels. 
We  see  it  around  varicosed  veins,  and  in  the  liver  cells. 

(c)  In  injiamifnatoTy  exudations,  and,  notably,  the 
lymph  effused  in  syphilitic  shin  eruptions  and  syphili- 
tic iritis.  The  staining  in  this  disease  is  out  of  pro- 
portion to  the  extent  and  duration  of  the  vascular 
congestion.  The  difference  can  be  explained  by  the 
supposition   that   the  poison  of  syphilis  is  peculiarly 


Chap.  XIV.  J 


Pigment  A  tiox. 


Ill 


destructive  to  the  red  blood-corpuscles,  and  this  view 
is  supported  by  the  fact  that  general  anaemia  is  one 
of  the  obvious  signs  of  constitutional  syphilis.  It  is 
v^^orthy  of  remark  that  in  syphilitic  stains  the  pigment 
is  confined  to  the  rete  and  the  tissue  beneath,  the 
superficial  horny  layer  of  the  epidermis  being  quite 


Fig.  7. — Section  of  Skin  at  site  of  an  old  Syphilide. 

a.  Lowermost  layer  of  rete,  deeply  pigmented  ;  h,  epidermis  devoid  of  pigment ; 
c,  sebaceous  gland;  d,  groups  of  pigment  granules  in  thickened  corium ;  e,  hair. 


free  (Fig.  7).  Either  the  pigment  must  be  decom- 
posed as  the  cells  become  cornified,  fresh  deposit 
going  on  meanwhile  in  the  retej  or  it  is  taken  over 
by  the  younger  cells  that  replace  the  old  ones  lost  by 
desquamation.  These  phenomena  are  not  confined  to 
syphilitic  stains  nor  to  any  inflammatory  pigmentation 
of  the  skin  ;  for  they  are  found  on  a  minor  scale  in  the 
natural  growth  and  decay  of  the  epidermis ;  another 
proof  that  pathological  changes  are  only  distorted 
forms  of  physiological  nutrition. 


112  Surgical  Pathology.  [Chap.  xv. 

{d)  The  'pigmentation  of  the  skin  around  patches 
of  leucoderma,  and  the  bronzing  of  the  skin  and 
buccal  mucous  membrane  in  Addison's  disease,  are 
of  uncertain  origin;  possibly  they  are  instances  of 
trophic  lesions  from  perversion  of  nerve  function. 


CHAPTER  XY. 

CALCAREOUS   DEGENERATION. 

Physiologically  calcification  occurs  in  the  de- 
velopment of  bone,  where  it  serves  the  definite  pur- 
pose of  giving  stability  to  the  osseous  framework.  But 
even  there  it  marks  the  limit  of  nutritive  activity  of 
the  matrix,  and  corresponds  to  the  final  stage  of 
formative  activity  of  the  bone  corpuscles  imprisoned 
within  the  lacunae.  In  caries  it  can  be  shown  that 
granulation  tissue,  the  anatomical  product  of  rarefying 
ostitis,  is  of  direct  vascular  origin,  and  not  the  result 
of  proliferation  of  the  bone  corpuscles.  Functionally, 
then,  ossification  must  be  considered  a  change  to  a 
higher  state  ;  but  from  a  nutritive  point  of  view  it  is 
lower  than  chondrifi  cation. 

It  may  be  primary,  as  in  calcification  of  the 
tunica  muscularis  of  the  medium-sized  arteries ;  it 
may  be  secondary  and  localised,  as  in  the  formation  of 
calcareous  plates  in  the  aorta  and  the  other  large 
arteries  afiected  with  atheroma ;  or  it  may  be 
secondary  and  widely  diffiised,  as  when  several  organs 
are  infiltrated  with  lime  salts  absorbed  from  the 
osseous  system. 

Thus,  then,  calcification  takes  place  under  two 
widely  different  conditions  :  (a)  from  an  inherent  or 
accidental   diminution   in   the  nutrition  of  a  tissue. 


Chap. XV.]      Calcareous  Degeneration,  113 

without  there  being  any  evidence  of  excess  of  lime- 
salts  in  the  blood ;  (6)  or  as  an  act  of  relief,  much  in 
the  same  way  that  "  chalk-stones  "  composed  of  urate 
of  soda  are  formed  about  the  joints  and  in  the 
cartilages  of  the  ear  in  gout,  or  as  "dealkalised  fibrin" 
is  deposited  from  the  blood  as  a  depui'ative  infiltration 
in  lardaceous  disease.  In  this  case  it  is  found  in  one 
or  more  organs.  The  lime  salts  pass  through  the 
walls  of  the  blood-vessels  in  a  state  of  solution,  and 
are  deposited  outside  in  the  interstitial  tissue  of  the 
parts  invaded,  in  the  lung  around  the  lobules_,  in  the 
kidney  between  the  tubuli  uriniferi. 

As  before  said,  calcification  implies  tissue  weak- 
ness. In  rickets,  it  is  true,  there  is  excessive  growth 
about  the  very  parts  where  the  cartilage  capsules  are 
undergoing  calcification,  but  this  in  itself  is  evidence 
of  perverted  nutrition,  growth,  and  development. 

In  old  age  it  is  rarely  absent,  and  here  it  la 
chiefiy  met  with  in  the  arteries  and  the  cartilages  of 
the  ribs  and  larynx. 

Anything  that  tends  to  diminish  the  vitality  of  a 
tissue  predisposes  to  calcification  ;  thus  we  can  under- 
stand why  it  is  so  frequently  found  in  inflammatory 
deposits,  and  notably  in  those  that  are  old,  and  the 
outcome  of  constitutional  weakness,  e.g.,  in  strumous 
glands,  and  phthisical  nodules  in  the  lungs. 

Fatty  degeneration  is  often  found  associated  with 
it ;  not  that  one  entails  the  other,  for  both  alike  are 
the  consequence  of  impaired  nutrition. 

Finality  in  the  series  of  degenerative  changes  is 
reached  in  calcification,  which  preserves  the  tissue 
elements  or  their  debris  from  further  decomposition. 
It  is  a  conservative  process,  but  not  necessarily  by 
design,  since  in  the  arterial  system  it  is  a  cause  of 
embolism,  thrombosis,  and  gangrene.  If  calcification 
sets  in  whilst  the  tissues  retain  their  structural  in- 
tegrity, the  lime  salts  are  deposited  first  in  the  inter- 
I 


114  Surgical  Pathology.  [Chap.  xv. 

cellular  substance,  and  then  in  the  prot<3plasni  of  the 
cells.  This  is  especially  the  case  in  new  growths,  e.g., 
sarcoma.  The  cells  which  are  hidden  by  the  opacity  of 
the  calcareous  granules,  can  be  again  brought  into  view 
by  dissolving  out  the  salts  with  a  dilute  mineral  acid. 

Calcification  may  be  partial  or  complete ;  in  the 
former  case  it  gives  a  roughness,,  and  adds  to  the 
friability  of  the  mass,  which  feels  something  like 
soft  mortar;  in  the  latter  the  part  is  completely 
petrified  and  brittle.  Compare  the  partially  calcified 
remains  of  a  chronic  abscess  with  the  dense  plates 
from  a  large  atheromatous  artery. 

The  salts  are  composed  for  the  most  part  of 
carbonate  and  phosphate  of  lime;  but  when  calcification 
happens  in  a  tissue  that  possesses  any  characteristic 
chemical  compounds,  these  will  be  found  mingled  with 
the  salts  of  the  earthy  bases.  Thus,  in  calcareous 
nodules  of  the  kidney  there  are  urinary  constituents. 

Under  the  microscope  the  calcified  patches  appear 
black  by  transmitted  light;  they  are  for  the  most  part 
angular  in  outline  and  composed  of  granules.  Some- 
times crystals  can  be  seen ;  this  is  the  more  likely  when 
calcification  has  taken  place  whilst  the  afiected  part 
retained  a  considerable  amount  of  moisture. 

On  the  addition  of  a  mineral  acid  the  carbonate 
of  lime  is  decomposed,  and  the  carbonic  acid,  set  free, 
escapes  in  the  form  of  minute  bubbles. 

Calcification  in  the  vascular  system. 

1.  In  the  heart. — Vegetations  on  the  aortic  and 
mitral  valves  often  become  calcified.  The  rigidity 
thus  acquired  renders  them  more  liable  to  be  detached, 
and  the  liability  is  increased  if  there  be  a  secondary 
ulcerative  endocarditis.  They  are  a  fertile  source  of 
arterial  embolism,  and  since  the  cohesion  of  these 
detached  vegetations  is  increased  by  the  calcification, 
large  arteries  (e.^.,  the  middle  cerebral)  are  not  un- 
commonly blocked. 


Chap. XV.]       Calcareous  Degeneration.  115 

2.  In  the  arteries. — Here  it  occurs  as  a  'primary 
and  secondary  change.  The  former  is  seen  in  the 
medium-sized  arteries,  such  as  the  tibials  and  cerebrals. 
This  primary  calcification,  one  of  the  signs  of  advanc- 
ing age,  begins  in  the  middle  coat.  The  deposit 
commences  around  the  nuclei ;  it  then  spreads 
throughout  the  cells,  which  lie  at  right  angles  to 
the  axis  of  the  vessels,  and  as  the  calcification  is 
unevenly  distributed,  it  takes  the  form  more  or  less  of 
an  irregular  succession  of  rings.  Portions  of  the 
arteries  are  sometimes  so  brittle  that  they  can  readily 
be  fractured  transversely. 

The  process  is  not  confined  to  the  muscular  coat, 
it  spreads  to  the  internal  and  external. 

In  this  way  the  surfaces  become  very  irregular, 
and  the  lumen  considerably  diminished.  The  loss  of 
elasticity  and  the  increased  friction,  together  with  the 
diminution  in  vitality,  favour  localised  or  difiused 
thrombosis,  and  so  become  important  factors  in  the 
production  of  senile  gangrene.  Other  forms  of  dege- 
neration, fatty  and  fibroid,  often  accompany  calcifi- 
cation. 

In  the  case  of  the  cerebral  arteries,  if  the  process 
be  slow,  a  partial  anaemia  sets  in,  and  the  brain, 
thereby  impoverished,  gradually  wastes,  at  the  same 
time  becoming  firmer.  Most  instances  of  so-called 
senile  softening  are  really  the  reverse — sclerosis. 
If  the  obstruction  be  great  and  localised,  especially 
if  the  heart  be  fatty,  and  still  more  if  the  blood 
coagulate  within  the  rigid  vessels,  portions  of  the 
brain  are  cut  off"  from  all  nutritive  supply,  and  con- 
sequently degenerate  and  soften. 

Secondary  calcification. — This  is  found  in  the 
aorta  and  other  large  arteries.  It  assumes  the  shape 
of  irregular  plates,  and  is  the  final  stage  of  athero- 
matous disease.  It  afiects  chiefly  the  inner  coat, 
for  in  the  large   vessels   the  muscular    is   but    little 


ii6  Surgical  Pathology.  [Chap,  x v. 

developed.  The  calcareous  plates  protect  the  vessel 
from  further  change,  and  even  serve  as  safeguards 
against  dilatation  at  their  immediate  seat.  They 
often  split  away  at  their  borders  from  the  surrounding 
non-calcified  portion  of  the  vessel,  and  may  even  be 
bodily  detached  and  swept  along  as  emboli  by  the 
blood  stream.  They  also  act  as  foreign  bodies,  and 
cause  the  blood  to  coagulate  upon  them ;  and  the 
thrombi  thus  formed  are  very  liable  to  be  detached, 
being  unable  to  withstand  the  force  of  the  current 
that  rushes  by. 

3.  In  the  veins. — Calcification  occasionally  afiects 
the  walls  of  the  veins.  It  is  also  seen  as  phleboliths 
in  their  interior. 

In  new  growtlis  it  is  by  no  means  rare.  It  has 
a  predilection  for  those  that  arise  in  connection  with 
bone,  and  especially  sarcoma  and  enchondroma.  The 
intercellular  substance  is  first  infiltrated,  and  then 
the  cells.  In  enchondroma  it  is  often  mixed  with 
true  ossification.  In  some  cases  the  distinction  can 
only  be  made  out  with  the  microscope  ;  but,  as  a  rule, 
calcification  is  more  patchy  and  irregular,  and  the 
absence  of  vessels  gives  to  the  naked-eye  appearances 
a  greater  opacity.  It  rarely  radiates  from  the  surface 
of  a  bone,  a  common  occurrence  in  ossifying  sub- 
periosteal sarcomas.  Other  tumours,  e.g..,  ovarian 
fibroids  and  dermoid  cysts,  sometimes  calcify. 

We  have  met  with  calcification  in  the  membranes 
of  the  brain  in  old  people,  and  as  the  sequel  of  trau- 
matic, spinal,  and  cerebral  meningitis. 

Calcification  of  the  adventitious  fibrous  capsules 
of  hydatid  cysts  after  the  death  of  the  parasite  is  not 
rare.  We  have  seen  such  a  shell  a  third  of  an  inch 
in  thickness.  It  may  even  occur  between  the  collapsed 
cysts  contained  within  the  adventitious  one. 


117 


CHAPTER  XYI. 

ALBUMINOID    INFILTRATION  I    SYNONYMS — AMYLOID, 
LARDACEOUS,    WAXY. 

In  some  chronic  wasting  diseases  there  is  found 
an  enlargement  of  the  liver,  spleen,  kidneys,  and 
lymphatic  glands. 

The  causes  in  the  order  of  frequency  run  thus  : — 
1.  Protracted  suppuration  in  caries  and  necrosis, 
empyema,  and  chronic  phthisis.  2.  Tertiary  syphilis. 
3.  Cancer.  4.  The  cachexia  produced  by  long  resi- 
dence in  hot  climates  and  exposure  to  malarial  in- 
fluence. 

The  above-named  organs  may  be  severally  or 
collectively  diseased.  The  same  change  is  sometimes 
met  with  in  the  mucous  membrane  of  the  intestine. 

The  general  characters  are  these :  increase  of 
size  and  density  of  the  organ,  a  peculiar  lustrous, 
waxy  appearance  on  section,  and  a  readiness  with 
which  the  lardaceous  substance  takes  the  staining  of 
certain  reagents,  such  as  iodine  and  methaniline 
violet. 

With  iodine  it  turns  a  deep  walnut  colour, 
changing  to  a  blackish  violet  tint  on  the  addition 
of  sulphuric  acid.  It  was  this  reaction  that  led 
Virchow  to  term  it  amyloid,  though  from  chemical 
analysis  it  is  now  known  not  to  belong  to  the  starchy 
group,  but  to  the  nitrogenous,  and  to  be  allied  to  albu- 
minous bodies. 

If  caustic  potash  be  added  to  a  section  stained 
with  iodine,  the  colour  vanishes,  and  it  reappears  on 
the  addition  of  an  acid.  If  a  portion  be  soaked  for 
some  time  in  potash,  it  no  longer  gives  the  reaction 


ii8  Surgical  Pathology.  [Chap. xvi. 

with  iodine  even  when  acidulated,  for  the  alkali 
dissolves  out  the  new  material,  and  to  a  much  greater 
extent  than  it  does  the  similar  constituents  of  healthy- 
tissue.  Whether  the  change  be  an  infiltration  or  a 
degeneration,  opinions  are  divided.  Dr.  Dickinson 
supports  the  former  view,  and  adduces  in  support  of 
it  the  enormous  increase  in  bulk  attained  by  the  liver 
and  spleen,  and  the  early  distribution  of  the  disease 
in  the  walls  of  the  arterioles.  He  believes  that  the 
material  is  dealkalised  fibrin,  which  infiltrates  the 
walls  of  the  vessels  and  exudes  from  them,  and  that  it 
is  the  result  of  a  depurative  process  whereby  the 
alkalinity  of  the  blood  is  diminished.  In  protracted 
suppuration  there  is  a  great  loss  of  potash  by  the 
discharge.  The  albuminoid  substance  is  deficient  in 
potash  and  phosphoric  acid,  whereas  it  contains  an 
excess  of  sodium  chloride  and  earthy  salts. 

It  must  not  be  forgotten  that  there  is  an  enormous 
loss  of  white  blood-corpuscles  by  suppuration,  although 
they  are  not  diminished  in  number  in  the  blood  ;  and 
this  may  be  by  no  means  an  unimportant  factor. 

Other  observers  take  excejDtion  to  these  views, 
both  as  to  the  exact  nature  of  the  substance  and  its 
origin.  They  say  that  other  bodies,  the  albumins, 
ordinary  fibrin,  etc.,  will  give  a  similar  colour  reaction 
with  iodine,  and  that  against  its  being  a  form  of  fibrin 
(which  is  a  colloidal  substance),  is  the  fact  that,  in 
inflammation,  filrin,  as  such,  does  not  exude  from 
the  vessels.  They  also  argue  that  the  special  liability 
of  certain  organs  to  be  affected,  and  that  not  in  a 
uniform  way,  is  opposed  to  the  theory  of  mere  in- 
filtration. One  fact  must  not  be  lost  sight  of,  and 
that  is,  the  tissues  afi'ected  play  an  important  part 
in  the  process,  whether  it  be  an  infiltration  or  de- 
generation, and  the  selection  may  be  as  much  on  the 
part  of  nutriendum  as  nutriens.  Those  who  main- 
tain that   it  is  a  degenerative   change,  refer  it  to  a 


ciiap.  XVI.]      Albuminoid  Infiltration.  119 

want  of  power  to  properly  nourish  certain  tissues 
from  a  vitiated  condition  o£  the  blood,  whether  it 
be  due  to  a  waste  of  alkali  and  corpuscles,  from 
suppuration,  or  to  the  materies  morbi  of  certain 
diseases,  such  as  syphilis,  cancer,  and  malaria. 

Anatomy. — The  change  begins  in  and  about  the 
walls  of  the  arterioles.  The  muscularis  is  first  affected. 
The  fibres  swell  and  look  glistening. 

In  the  kidney  the  walls  of  the  vessels  of  the 
Malpighian  bodies  and  the  vasa  recta  of  the  pyramids 
are  notably  diseased.  Soon  the  epithelium  becomes 
involved,  and  it  is  said  exudative  casts  of  the  same 
substance  may  be  found  in  the  tubes,  but  these  are 
perhaps  cast-off  degenerated  epithelium. 

In  the  liver  the  intermediate  arterial  zone  fi.rst 
suffers. 

In  the  spleen  the  Malpighian  bodies  stand  out 
in  bold  relief,  looking  like  boiled  sago  grains,  hence 
the  term  "sago  spleen." 

In  the  intestine  (particularly  the  small),  the  tips 
of  the  papillae  first  present  the  waxy  change. 

Statistics  show  that  this  disease  does  not  appear 
within  three  months  of  the  commencement  of  sup- 
puration. 

Fatty  degeneration  is  found  associated  with  the 
lardaceous  change ;  in  fact,  the  albuminoid  substance 
may  itself  undergo  that  transforma.tion.  There  is 
not  sufficient  evidence  to  show  that  it  organises,  nor 
that  it  disappears  when  far  enough  advanced  to  be 
diagnosed  during  life. 

The  possibility  of  its  occurrence  must  always  be 
borne  in  mind  in  the  treatment  of  chronic  suppuration. 
Other  reasons  apart,  it  would  point  to  amputation 
in  preference  to  excision  of  diseased  joints. 

Yessels  affected  by  the  change  are  more  permeable 
to  fluids ;  he;nce  the  polyuria  from  affection  of  the 
kidney,  and  intractable   diarrhoea  when   the  villi   of 


I20  Surgical  Pathology.  [Chap.  xvi. 

the  intestine  are  involved.  The  enlargement  of  the 
liver  does  not  cause  jaundice  jjer  se.  When  this  is 
present,  it  depends  either  upon  catarrh  of  the  bile 
ducts,  or  pressure  of  enlarged  glands  in  the  transverse 
fissure  (Murchison). 

Corpora  ainylacea. — These  are  for  the  most 
part  minute  round  or  oval  bodies.  They  have  been 
termed  amyloid  on  account  of  the  colour  reaction 
they  give  with  iodine,  or  with  iodine  and  sulphuric 
acid ;  but  several  authorities  believe  that  they  are 
nitrogenous  in  composition.  The  colour  test  cannot 
be  relied  upon  as  an  absolute  indication  of  their 
nature,  for  it  led  to  an  erroneous  interpretation  in 
the  case  of  lardaceous  disease,  which,  however,  is  widely 
difierent  in  its  pathology  from  the  bodies  in  question. 
Lardaceous  disease  is  the  outcome  of  a  general  dys- 
crasia,  whilst  the  corpora  amylacea  are  purely  local 
phenomena,  and  from  the  frequency  with  which  they 
are  found  apart  from  other  morbid  changes  (e.g.,  in 
the  prostate  gland)  they  are  of  very  little  clinical 
import. 

They  are  most  common  in  the  prostate,  and  in 
the  central  nervous  system,  but  they  have  been  met 
with  in  the  lungs,  in  the  mucous  and  serous  mem- 
branes, and  many  other  situations. 

In  the  nervous  system  they  are  by  no  means  rare 
as  a  sequel  of  chronic  degenerative  changes. 

They  are  met  with  in  the  grey  and  white  matter 
of  the  brain  and  cord,  in  the  choroid  plexuses  of  the 
cerebral  ventricles,  in  the  pineal  and  pituitary  glands, 
and  in  the  optic  nerve  and  retina. 

They  are  liable  to  undergo  calcareous  infiltration. 
Structurally  they  consist  of  a  homogeneous  material 
frequently  arranged  in  concentric  laminae.  The 
lamination  is  probably  due  to  successive  depositions 
from  without. 

With  iodine  they  give  a  blue,  yellow,  green,  or 


Chap.  XVII.]  Trophic  Lesions.  121 

brown  colour.  The  extent  of  the  three  latter  tints 
is  dependent  on  the  amount  of  albuminoid  matter 
present.  Iodine  stains  starchy  substances  blue,  and 
albuminoid  yellow  or  brown. 

Sulphuric  acid  brings  out  or  heightens  the  effect 
of  iodine. 

Amyloid  bodies  have  not  been  converted  into 
glucose,  a  fact  which  tells  against  theh^  being  closely 
affined  to  starch. 


CHAPTER    XYII. 

TROPHIC       LESIONS. 

The  causes  of  deviations  from  normal  nutrition 
must  be  sought  (1)  in  the  life  processes  of  the 
tissues  themselves  ;  (2)  in  modifications  of  nutriti^^e 
supply,  qualitative  and  quantitative  ;  and  (3)  in  morbid 
states  of  innervation. 

The  tissues,  like  individuals,  have  an  allotted 
period  of  healthy  existence,  after  which  they  waste 
and  die,  apparently  independent  of  vascular  change 
or  deprivation  of  nervous  influence  ;  e.g.^  fatty  de- 
generation of  the  corneal  cells  and  coats  of  the  blood 
vessels.  ( Yide  Atrophy. ) 

Many  lesions  owe  their  origin  to  abnormal  con- 
ditions of  the  blood  and  vessels.  Long-standincf 
venous  congestion  leads  to  atrophy,  pigmentation,  and 
fibroid  induration,  acute  hypersemia  to  exudations 
and  haemorrhages.  The  composition  of  the  blood 
is  also  of  great  moment.  On  this  depend  the  so-called 
cachexias  of  syphilis  and  pyaemia,  and  the  rapid  fatty 
softenings  of  protoplasm  in  the  acute  specific  fevers 
and  septicaemia. 

But  from  the   very  intimate  connection  betiveen 


122  Surgical  Pathology.        [Chap.  xvii. 

nerve  endings  and  the  elements  of  the  tissues,  and 
the  evidence  of  physiological  relationship  between 
a  healthy  state  of  the  nervous  system  and  the  proper 
discharge  of  functions  of  organs,  it  is  not  surprising 
that  any  wide  divergence  from  the  normal  state  of 
the  one  should  show  itself  in  a  corresponding  modifi- 
cation of  nutrition  and  function  of  the  other. 

Trophic  nerves. — Probably  there  are  special 
trophic  fibres.  If  so,  in  the  case  of  the  spinal  nerves 
they  take  the  same  course,  and,  in  fact,  are  blended 
with  the  motor,  sensory,  and  sympathetic  bundles. 

Meissner  has  shown,  that  if  the  innermost  fibres 
of  the  fifth  cranial  nerve  be  divided,  inflammation 
of  the  eye  will  result,  although  sensation  remain 
intact ;  whereas  if  only  the  outer  fibres  be  cut  (sensa- 
tion being  to  a  great  degree  lost)  no  such  lesion  is 
observed.  In  a  case  of  inflammation  of  the  fifth 
nerve  that  came  under  my  notice,  there  was  severe 
trifacial  neuralgia,  perforating  ulcer  of  the  cornea, 
and  rapid  wasting  of  the  masseter  muscle. 

The  cutaneous  system  presents  numerous  in- 
stances of  the  effect  of  perverted  function  of  the 
nervous  system,  both  as  to  degree  and  kind.  Thus, 
temporary  or  permanent  blanching,  or  loss  of  hairy 
has  been  known  to  follow  mental  strain  and  severe 
neuralgia.  Irregular  pigmentation,  as  in  leucoderma, 
is  believed  to  be  of  neurotic  origin.  But  the  more 
frequent  lesions  are  those  where  the  disordered  nutrition 
of  the  epidermis  and  true  skin  shows  itself  in  the 
forms  of  glossy  smoothness,  eruptions,  and  ulcerations. 
Here  it  may  be  remarked  that  these  lesions  are  more 
decided  when  the  nerves  are  irritated,  than  when 
completely  divided.  In  the  latter  case  the  nutrition 
is  defective,  and  there  is  loss  of  power  of  with- 
standing injuries  and  repairing  their  consequences  ; 
the  process  is  passive  rather  than  active. 

Vesicular   eruptions  are  the  most  common;  e.^., 


Chap.  XVII.] 


Trophic  Lesions. 


123 


heroes  zoster.^  from  perineuritis  of  the  spinal  nerves, 
and  herpes  labialis  and  frontalis  in  affections  of  the 
fifth  cranial.  The  same  is  true  of  traumatic  irritation. 
The  skin  supplied  by  the  affected  nerve  often  becomes 
glossy,  like  a  polished  scar,  though  at  others  it  is 
rougher  than  natural,  presenting  a  desquamating, 
branny  appearance,  analogous  to  the  unilateral  furring 


Cb 


Fig.  8. — Portion  of  Shot  embedded  in  Posterior  Tibial  Nerve. 

a.  Nerve  fasciculi ;  5,  blood-vessel ;  c,  the  foreign  body.  The  inflammatory 
exudation  has  organised.  In  some  fasciculi  the  nerve  fibres  are  fewer  than 
normal. 


of  the  tongue,  from  irritation  of  the  gustatory  nerve 
or  its  trunk.  Injuries  of  the  nerve-centres^  leading  to 
ulceration  and  sloughing,  as  seen  in  the  formation  of 
hed-sores,  from  fracture  of  the  spine.  Here  the  de- 
struction of  tissue  is  out  of  proportion  to  the  extent  of 
continued  pressure  on  one  part,  from  inability  to  shift 
position.  Moreover,  in  paraplegia  the  sores  form  over 
the  sacrum,  whereas  in  hemiplegia  there  is  sloughing 
of  the  buttock,  on  the  side  opposite  the  cerebral  lesion. 
Painful  irritable  ulcers,  in  the  floor  of  which  the 
terminal  fibres  of  the  nerves  are  probably  exposed, 


124  Surgical  Pathology.         [Chap.  xvii. 

are  very  intractable,  and  often  refuse  to  heal  until 
those  fibres  have  been  destroyed  by  caustics,  or  the 
fasciculi  supplying  them  have  been  divided  (Hilton). 

Profuse  sweating  has  been  observed  over  the  area 
of  nerve  disturbance. 

Although  paralysis  of  the  vaso-motor  nerves,  and 
in  some  cases  active  vaso-motor  dilatation,  from  stimu- 
lation (Strieker),  may  play  a  conspicuous  part  in  the 
causation  of  extensive  cedema,  and  alteration  of  tem- 
perature, it  is  probably  of  secondary  importance  as 
compared  with  affection  of  the  trophic  fibres.  Such 
oedema  occurs  in  some  cases  of  injury  to  the  spinal 
cord,  and  also  in  certain  diseases,  e.g.^  locomotor 
ataxia.     It  may  be  transient  or  permanent. 

Perforating  ulcer  of  tlie  foot. — Mr.  Savory 
and  others  have  pointed  out  that  this  is  the  conse- 
quence of  nerve  lesion,  sometimes  local,  more  often 
central.  The  interstitial  tissue  of  the  nerves  is 
increased,  chiefly  relatively,  for  the  nerve  fibres  are 
fewer  and  smaller  than  normal.  The  smaller  fibres, 
which  are  probably  trophic  and  sensory,  suffer  more 
than  the  larger  ones. 

There  is  abundant  evidence  of  disordered  nutrition. 
The  skin  is  cold,  frequently  congested,  and  liable  to 
profuse  paralytic  perspiration.  At  times,  too,  it  is 
thickened,  especially  about  the  toes  ;  and  the  sensi- 
bility is  diminished.  The  ulcer  is  often  seated  at  the 
base  of  a  corn,  over  the  ball  of  the  great  toe,  or  outer 
part  of  the  foot,  i.e.,  where  the  greatest  pressure  is 
brought  to  bear.  It  leads  to  a  deep,  but  usually 
narrow,  sinus,  which  may  traverse  the  whole  thickness 
of  the  foot,  or  terminate  at  a  diseased  bone.  It  is 
very  intractable,  and  liable  to  return  after  it  has 
healed.  It  has  been  found  in  anaesthetic  leprosy, 
locomotor  ataxia,  caries  of  the  spine,  and  in  congenital 
deformities  of  the  feet,  which  are  known  to  be  some- 
times  associated   with   disordered   innervation,   from 


Chap.  XVII.]  Trophic  Lesions.  125 

defective  development  of  the  spinal  centres  and 
nerves. 

Connective-tissue  hypertrophy. — Short  of 
ulceration,  the  soft  tissues  of  the  foot  and  leg  may 
undergo  hypertrophy,  giving  the  part  a  coarse, 
clubbed,  distorted  look.  The  thickening  is  due  to  an 
overgrowth  of  an  ill-developed  connective  tissue, 
similar  to  that  seen  in  elephantiasis.  It  is  more  than 
probable  that  many  cases  looked  upon  as  spontaneous 
local  perversions  of  nutrition  are  really  the  outcome 
of  nerve  lesions. 

Muscular  system. — Paralysed  muscles  waste 
from  want  of  their  proper  physiological  stimulus;  but 
in  addition  to  this  there  is  a  more  rapid  atrophy, 
accompanied  by  a  speedy  decline  in  electric  contrac- 
tility where  the  trophic  nerves  are  involved.  Compare 
the  state  of  the  muscles  of  the  face  when  palsied  in  an 
ordinary  case  of  hemiplegia  with  that  observed  in 
injury  to  the  trunk  of  the  seventh  nerve,  whether 
directly  from  fracture  of  the  base  of  the  skull,  or  from 
the  pressure  of  inflammatory  exudation,  from  syphilis, 
or  exposure  to  cold,  or  caries  of  the  petromastoid  bone. 

Osseous  system. — The  repair  of  a  fracture  is 
liable  to  be  imperfect,  or  indefinitely  delayed,  when  the 
nerve  or  nerve-centre  supplying  the  part  is  injured  ; 
thus,  if  the  cord  be  crushed  in  the  dorsal  region,  and 
a  femur  and  humerus  broken  at  the  same  time,  union 
will  occur  in  the  latter,  perhaps  not  in  the  former. 

Occasionally  bone  is  deposited  in  unusual  situations. 
Dr.  Buzzard  ("Clinical  Lectures  on  Diseases  of  the 
Nervous  System,"  p.  225)  describes  a  case  of  locomotor 
ataxia,  in  which  "a  bony  process  appeared  to  occupy  the 
position  of  the  right  rectus  f  emoris  muscle ;  it  stretched 
obliquely  downwards,  and  somewhat  inwards,  for  a 
length  of  about  nine  inches."  The  hip  joint  was 
affected  on  the  same  side.  Fracture  of  the  bones 
sometimes  occurs  in  locomotor  ataxy;  this  is  no  doubt 


126  Surgical  Pathology.         [chap.  xvii. 

traumatic,  but  it  is  rendered  more  easy  by  reason  of 
atrophy  from  disease  (the  patient  being  paralysed) 
and  trophic  erosion,  when  this  is  present. 

The  joints. — The  joints  are  subject  to  remark- 
able errors  of  nutrition  from  lesions  of  the  nerve- 
centres,  acute  or  chronic,  traumatic  or  spontaneous. 
Injury  of  the  cord  from  fracture  of  the  spine  some- 
times induces  rapid  inflammatory  eflrusion. 

Charcot's  disease. — Ataxic  arthropathy. 
Charcot  has  described  cases  of  the  most  extensive 
disorganisation  of  the  joints  in  persons  affected  with 
sclerosis  of  the  spinal  cord,  especially  of  the  posterior 
columns — locomotor  ataxy.  During  life  the  physical 
signs  simulate  those  of  chronic  rheumatic  arthritis, 
for  which,  in  fact,  they  have  been  mistaken;  but  there 
are  many  important  differences,  so  that  one  need  never 
be  left  in  doubt. 

In  locomotor  ataxia  there  is  often  considerable 
effusion  into  the  joint ;  in  rheumatic  arthritis  little  or 
none.  This  is  one  of  the  factors  of  dislocation,  the 
other  being  absorption  of  the  head  of  the  bone,  e.g.^ 
the  femur. 

In  locomotor  ataxia  the  onset  is  more  sudden 
and  the  course  more  irregular,  and  the  process 
may  subside  partially  or  entirely,  whereas  in  rheu- 
matic arthritis  the  disease  is  slowly  and  surely  pro- 
gressive. 

In  locomotor  ataxia  the  formation  of  osteophytes 
is  quite  the  exception ;  in  rheumatic  arthritis  it  is 
constant. 

The  joints  are  affected  in  the  following  order  of 
frequency  in  locomotor  ataxia  : — knee,  shoulder,  hip. 
Monarticular  rheumatism  is  most  commonly  met 
with  in  the  hip. 

The  absorption  of  the  cartilages  may  be  complete  ; 
even  the  head  and  neck  of  a  long  bone  (e.^.,  the 
femur)  may  disappear  (Fig.  9).     Other  parts  of   the 


Chap.  XVII.] 


Trophic  Lesions. 


127 


bone  may  also  be  eroded,  e.g.^  the  iliac  expansion  of 
the  hip.  The  disease  affects  one  or  more  joints.  In 
a  case  described  by  M.  Fere  several  were  involved. 

A  patient  between  fifty  and  sixty  years  of  age 
came  under  the  care  of  the  writer,  complaining  of 
'•'  lameness   from  rheumatics  of   the  great  toe."     On 


Fig.  9. — Osseous  and  Articular  Lesions,  from  a  case  of  Locomotor  Ataxy. 

A,  Left  iliac  bone :  erosion  of  acetabulum  and  neighbouring  part ;  b,  left 
femur,  showing  complete  absorption  of  head  (Fere). 


examination,  the  metatarso-phalangeal  articulation  of 
the  right  great  toe  was  found  to  be  the  seat  of  con- 
siderable effusion,  which  had  slowly  developed  during 
a  period,  of  several  months ;  the  skin  over  the  joint 
was  deeply  congested ;  there  was  absence  of  patellar 
reflex;  the  "  Argyll -Robertson  pupil"  was  well 
marked ;  there  had  been  lightening  pains  on  and  ofi* 
for  seven  years ;  no  other  joint  was  affected ;  there 
was  no  history  of  gout,  either  personal  or  family. 
Oenito-iirmary  system. — Attacks  of   profuse 


128  Surgical  Pathology.        [Chap,  xviii. 

hsematuria,  synchronous  with  lightening  pains,  have 
been  observed  by  my  colleague,  Mr.  Page,  in  a  case  of 
locomotor  ataxia  ;  the  urine  was  quite  normal  in  the 
intervals  {^Brit.  Med.  Journal,  vol,  i.,  p.  772,  1883). 

The  writer  has  seen  painless  swelling  of  the 
testicles  along  with  transient  attacks  of  cystitis. 
Perhaps  these  phenomena  were  chiefly  due  to  in- 
creased blood-capillary  pressure  from  active  vaso- 
motor dilation  referred  to  by  Strieker. 

There  can  be  little  doubt  but  that  trophic  and 
vaso-motor  paralyses,  from  crushing  of  the  spinal 
cord,  cause  a  perversion  of  nutrition  of  the  urinary 
tract,  and  play  an  important  part  in  the  causation  of 
cystitis  and  surgical  kidney. 

The  eye. — In  addition  to  what  has  been  said  of 
acute  inflammatory  destruction  of  the  eye-ball  in 
aflfections  of  the  fifth  nerve,  there  may  be  added  that 
double  descending  optic  neuritis  is  frequently  seen 
in  coarse  lesions  of  the  brain  and  spinal  cord  ;  e.g., 
meningitis  (simple,  tubercular,  and  syphilitic),  intra- 
cranial tumours,  and  cerebral  and  spinal  scleroses. 
Then  there  is  grey  atrophy  of  the  disc  in  locomotor 
ataxia,  etc. 


CHAPTEH   XVIII. 

SYPHILIS. 

Syphilis  is  a  specific,  contagious,  non-infectious 
disorder,  characterised  by  a  period  of  incubation 
varying  from  one  to  seven  weeks,  by  the  deve- 
lopment of  an  indurated  sore  at  the  seat  of  inocula- 
tion in  the  "acquired "  disease,  and  by  an  efiiorescence 
or  rash,  and  usually  by  other  inflammatory  lesions. 
It  is  so  strongly  protective  against  subsequent  attacks 
that  the   immunity  conferred  lasts  for  the  whole,  or 


Chap.  XVIII.]  Syphilis.  129 

the  greater  j)art,  of  a  lifetime,  It  can  be  comiDuni- 
cated  from  parent  to  offspring  by  indirect  contagion. 

The  local  sores  have  been  described  in  chapter  iii., 
but  there  remain  for  discussion  the  rival  theories 
of:— 

The  unity  aud  duality  of  sypMlitic  cliaii- 
cres. — Some  syphilographers  maintain  that  there  is 
but  one  sore,  though  this  may  manifest  itself  in  a 
non-infective  or  purely  local  form,  or,  on  the  other 
hand,  give  rise  to  constitutional  symptoms.  According 
to  this  view,  soft  and  hard  chancres,  so-called,  are 
relatively  pathological  accidents  ;  and  the  difference  in 
the  results  is  explained  by  the  supposed  absence  or 
presence  of  the  germs  of  syphilis.  But,  arguing 
from  the  analogy  offered  by  other  specific  diseases, 
these  germs  must  be  considered  as  the  essential 
elements  concerned  in  the  reproduction  of  the  poison, 
and  consequently  in  the  propagation  of  the  disease. 

On  etiological  grounds,  no  greater  mark  of  distinc- 
tion between  an  ulcer  caused  by  simple  chemical  irrita- 
tion and  one  produced  by  a  specifi.c  virus  can  be  well 
conceived.  To  meet  this  objection,  the  supporters  of 
the  "  unity  "  theory  suppose,  that  either  the  germs  of 
syphilis  are  destroyed  by  the  local  ulcerative  process, 
or  that  they  do  not  find  in  the  system  a  fitting  soil 
for  their  development.  The  former  hypothesis  is 
untenable ;  for  the  poison  is  absorbed  by  the  lympha- 
tics long  before  any  destructive  action  can  be  set  up 
at  the  seat  of  inoculation,  as  shown  by  the  fruitless 
attempts  to  prevent  infection  by  early  excision  of  the 
sore.  From  the  nature  of  things,  it  is  next  to 
impossible  to  prove  the  latter,  since  no  one  would 
think  of  inoculating  a  number  of  persons  to  see  if 
any  were  proof  against  infection.  The  tenacity  of 
life  possessed  by  the  germs  is  probably  too  great  for 
them  to  succumb  to  the  action  of  chemical  products 
of  decomposition  in  the  sore ;  for  constitutional 
J 


130  Surgical  Pathology.        [Chap.  xviii. 

syphilis  may  certainly  be  conveyed  by  tlie  secretions 
of  most  actively  pliagedsenic  chancres. 

Mr.  Savory  considers  that  the  evidence  afforded 
by  gonorrhoea,  which  is  in  most  cases  only  a  local 
affection,  but  which,  in  a  few,  leads  to  general  dis- 
turbance, upholds  the  unity  theory.  But  the  specific 
nature  of  gonorrhoeal  pus  is  denied  by  some  of  the 
greatest  authorities  (Ricord,  Lane) ;  so  the  grounds 
for  analogical  inference  are  untrustworthy. 

Attention  has  also  been  drawn  to  the  fact  that 
scarlatina  does  not  always  give  rise  to  the  usual  con- 
stitutional symptoms.  But  this  by  no  means  shows 
that  the  poison  is  one  whit  the  less  specific,  for  an 
individual  infected  from  such  a  modified  source 
may  develop  all  the  characteristic  features  of  the 
disease.  It  is  not  the  absence  of  constitutional 
symptoms,  but  the  degree  of  manifestation. 

Again,  it  is  said  that  there  are  many  intermediate 
forms  between  soft  and  hard  chancres.  No  doubt 
there  are  ;  but  the  simulation  of  one  morbid  process 
by  another  does  not  prove  an  essential  relationship 
between  them;  e.g..,  syphilitic  acne  and  acute  lichen 
imitate  the  papular  state  of  small-pox  ;  but  each  is 
distinct  from  the  others.  There  is  also  a  likeness 
between  the  symptoms  of  vaccinia,  variola,  and 
varicella ;  still  these  diseases  are  none  the  less 
specific.  Those  who  believe  in  the  dualism  of 
syphilitic  sores  explain  the  apparent  transitional 
forms  by  the  effects  of  local  irritation,  or  by  some 
peculiarity  of  the  tissues  in  different  individuals. 
By  sharf)  or  continued  irritation  a  hard  chancre  may 
be  made  to  suppurate,  and  a  soft  one  to  indurate,  to 
a  certain  extent.  The  subsequent  induration  of  a 
previously  soft  suppurating  chancre  may  also  be  due 
to  double  inoculation  at  the  same  time,  each  virus 
producing  its  own  results  in  its  own  appointed  time. 

Although  there  are  pathological  grounds  for  this 


Chap.  XVIII.]  SVPHILIS.  I3I 

conflict  of  opinions,  the  practical  rule  is  never  to  let 
a  patient  suSering  from  a  venereal  sore  pass  from 
notice  until  sufficient  time  has  elapsed  for  the  appear- 
ance of  constitutional  symptoms,  whether  this  seems 
likely  to  be  the  case  or  not. 

J.  Hunter  maintained  that  gonorrhoea  and  syphilis 
were  due  to  the  same  poison,  from  the  fact  that  he 
could  induce  syphilitic  infection  by  inoculation  with 
the  pus  of  acute  "  specific  "  urethritis ;  but  he  did  not 
take  into  account  the  existence  of  urethral  chancres 
and  the  infectivity  of  the  blood  and  secretions  of  the 
subjects  of  constitutional  syphilis. 

Secondary  and  tertiary  sypMlis. — Syphilis 
differs  from  other  exanthematous  fevers  by  the  long 
tiaie  through  which  the  poison  remains  active. 

The  group  of  secondary  symptoms,  including  the 
eruption,  mucous  tubercles,  ulceration  of  the  mouth 
and  throat,  loss  of  hair,  indurations  of  the  lymphatic 
glands,  iritis,  and  rheumatic  affections  of  the  muscles 
and  joints,  usually  pass  away  within  the  first  twelve  or 
eighteen  months.  Then  there  is  a  period  of  quiescence 
which  may  occupy  months  or  years,  or  extend  through 
the  patient's  lifetime.  In  the  latter  case,  the  disease 
may  be  considered  as  eradicated ;  in  the  former,  the 
poison  has  lain  dormant,  or  incapable  of  manifesting 
itself  by  obvious  signs.  After  this  interval  it  again 
acquires  activity,  and  then  we  arrive  at  what  is 
called  the  tertiary  stage.  In  favour  of  the  view  of 
the  continued  potency  of  the  virus  is  the  uncertainty 
as  to  when  the  power  of  transmission  from  parent  to 
offspring  ceases,  and  the  fact  that  a  woman  may  bear 
an  apparently  healthy  child  between  the  births  of  two 
syphilitic  ones,  all  by  the  same  father.  But  many 
pathologists  regard  tertiary  syphilis  as  the  sequel,  and 
not  the  direct  result,  of  by-gone  infection.  They 
consider  that  the  vitality  of  the  tissues  was  lowered 
during  the  secondary  period,  and  that,  as  in  scrofula. 


132  Surgical  Pathology.        [Chap,  xviii. 

these  tissues  then  readily  pass  into  a  state  of  chronic 
inflammation.  The  non-transmissibility  of  the  dis- 
ease in  the  advanced  tertiary  stage  seems  to  lend 
weight  to  this  supposition ;  but  against  it  are  those 
cases  in  which  the  secondary  symptoms  pass  without 
a  break  into  the  tertiary.  Moreover,  some  ^  of  the 
tertiary  lesions  are  anatomically  characteristic  of 
syphilis  (notably,  gummy  tumour),  whereas  the 
"  sequelse "  of  other  specific  disorders  {e.g.,  scarlet 
fever)  are  far  from  being  so ;  and,  even  in  them, 
there  is  no  absolute  proof  that  the  so-called  "  after 
results  "  are  not,  as  far  as  causation  is  concerned,  the 
direct  outcome  of  specific  irritation. 

The  dogmatic  assertions,  "syphilis  once,  syphilis 
ever,"  and  "  syphilis  is  a  flesh  and  blood  disease," 
imply  not  only  a  belief  that  the  tertiary  symptoms 
are  specific,  like  the  secondary,  but  that  the  patient  is 
never  freed  from  the  original  taint.  The  latter  is 
opposed  to  the  experience  of  many  surgeons. 

The  type  of  the  inflammatory  processes  changes 
considerably,  for  whilst  the  lesions  of  secondary 
syphilis  tend  to  spontaneous  cure,  those  of  the  tertiary 
period  are  much  more  permanent,  and  show  a  greater 
liability  to  relapses. 

Secondary  syphilis,  as  regards  tissue  selection, 
expends  the  greater  part  of  its  virulence  upon  the 
cutaneous  and  mucous  structures.  Tertiary  syphilis 
affects  these  parts  as  well,  but  it  is  also  very  prone  to 
attack  the  viscera  and  the  osseous  and  nervous  systems. 

Another  argument  advanced  in  support  of  the 
view  that  secondary  syphilis  is  chiefly  a  blood  disease, 
and  tertiary  an  induced  morbid  state  of  the  tissues,  is 
the  symmetrical  disposition  of  the  local  manifestations 
in  the  former,  and  the  irregular  distribution  in  the 
latter.  But  whilst  this  holds  good  in  the  majority  of 
cases,  there  are  too  many  exceptions  to  warrant  its 
general  a>pplication. 


Chap.  XVIII.] 


Syphilis. 


133 


The  characteristic  lesions  of  tertiary  syphilis  (gum- 
mata)  are  by  some  classed  among  the  tumours,  or  new 
growths,  but  for  no  good  reason.  They  are  simply 
masses  of  inflammatory  exudation,  and  differ  from 
many  tumours  in  that  they  cannot  be  enucleated,  and 
from  the  malignant  ones  further  that  they  do  not 
generalise  ;  moreover,  they  follow  the  course  of  inflam- 
matory exudations  in  general  in  their  tendency  to 
arrive  at  some  typical  end — -absorption,  disintegration, 
caseation,  etc.  They  are  chiefly  found  in  the  skin  and 
subcutaneous  tissue ;  in  the  mucous  and  submucous 
tissues,  particularly  in  the  mouth  and  pharynx ;  in 
the  internal  organs,  e.g.^  the  liver,  kidney,  and  brain; 
and  lastly  in  bone.  They  vary  in  size  from  that 
of  a  hempseed  to  a  large 
wahiut.  They  may  be 
looked  upon  as  aggregates 
of  microscopical  foci  of 
inflammation,  which,  at 
first  vascular  throughout, 
subsequently,  from  de- 
generative and  indurative 
changes,  show  three  fairly 
distinct  zones  :  an  in- 
ternal, composed  of  fatty 
and  granular  debris  de- 
void of  vessels  ;  a  middle 
one,  where  the  cells  are 
round  and  oval  and  under- 
going   atrophy;    and   an 

external,  highly  vascular  and  exudative.  No  hard 
and  fast  line  is  to  be  drawn  between  these  zones ;  they 
shade  into  one  another,  since  they  represent  overlapping 
stages  of  growth  and  decay.  The  cells  are  imbedded  in 
a  ground  substance  of  lymph,  sometimes  fibrillated, 
giving  a  spun-glass  appearance,  but  more  often  so 
thickly  set  with  cells  as  to  be  scarcely  visible  (Fig.  10). 


^^' 


17 


Fig,  10. — Syphilitic  gimima  of  the 
Liver. 
a.  Centres  of  nodes  in  which  the  cells 
have  became  granular ;  6,  periphery 
of  the  nodfs:  c,  vessel  (x  100).    {After 
Cornil  and  Ranvier.) 


134  Surgical  Pathology.        [Chap. xviii. 

An  old  gumma  appears  to  tlie  naked  eye  as  a 
greyish  yellow  mass,  surrounded  by  a  zone  of  fibrous 
tissue.  It  is  quite  firm,  and  has  less  tendency  than 
tubercle  or  infarctions  to  soften  in  the  centre.  In  the 
internal  organs  it  rarely  breaks  down,  but  the  pro- 
ducts of  its  degenerations,  and  those  of  the  tissue 
destroyed  by  its  invasion,  are  slowly  absorbed,  deep 
puckered  cicatrices  marking  the  spot  where  it  had 
existed.  In  the  superficial  structures,  where  it  is 
more  exposed  to  irritation,  it  very  often  ulcerates, 
causing  widespread  serpiginous  sores,  the  discharge 
from  which  is  at  first  glairy  from  mucoid  or  colloid 
degeneration  of  the  lymph  and  cells.  This  may  begin 
by  superficial  ulceration  and  gradual  disintegration, 
or  the  whole  mass  may  slough  out. 

The  caseation  is  dependent  firstly  upon  an  inherent 
low  vitality  of  the  exudation  (aplastic),  and  secondly 
upon  capillary  thrombosis,  the  consequence  of  in- 
flammation of  the  walls  of  the  vessels.  Amongst  the 
amorphous  debris  may  be  seen  stellate  crystals  of 
stearic  acid,  and  plates  of  cholesterine.  Giant  cells 
are  occasionally  present  at  the  periphery,  but  they  are 
not  so  common  as  in  tubercle. 

Syptiilitic  eruptions. — Unless  rupiabe  regarded 
as  essentially  of  syphilitic  origin,  all  the  forms  of 
cutaneous  eruptions  in  syphilis  are  modifications  of 
non-specific  varieties.  There  are  certain  peculiarities, 
however,  that,  taken  in  the  aggregate,  give  to  syphilitic 
eruptions  a  well-defined  character.     They  are  ; 

1.  Polymorijhism. — The  same  patient  may  exhibit 
at  once  what  is  known  as  a  mixed  syphilide,  i.e.,  an 
association  of  different  types  of  cutaneous  rash;  e.g., 
papular,  scaly,  tubercular,  etc.  This  is  often  seen  in 
the  secondary  or  exanthematous  stage.  It  is  also 
met  with  in  the  tertiary  period.  But  it  should  be 
understood  that  this  polymorphism  depends  rather 
upon  the  degree  of  local  inflammation,  than  upon  any 


Chap.  XVIII.]  Syphilis..  135 

well-marked  variation  in  the  morbid  process.  Thus 
papular  passes  insensibly  into  tubercular  syphilide, 
the  latter  indicatino-  a  more  extensive  exudation,  and 
therefore  a  greater  obstruction  to  the  capillary  cir- 
culation, and  liability  to  ulceration  and  interstitial 
destruction  of  tissue.  Again,  syphilitic  psoriasis  par- 
takes very  much  of  the  nature  of  an  inflammatory 
desquamation,  as  well  as  of  epithelial  hyperplasia. 

2.  Selection  of  site. — Though  no  part  of  the 
skin  is  exempt  from  the  efflorescence  or  secondary 
roseola,  the  trunk,  and  fronts  of  the  axillse  and 
elbows,  are  favourite  situations  for  this  form  of 
eruption.  Tubercular  syphilide  has  a  proclivity  for 
the  face,  and  especially  the  forehead — ''  the  mark  of 
the  beast,"  as  it  has  been  aptly  termed.  Squamous 
syphilide  in  the  shape  of  palmar  and  plantar  psoriasis 
is  well  known.  The  special  liability  of  certain  parts 
of  the  skin  to  the  action  of  the  virus  is  observed  in 
other  speciflc  fevers. 

3.  Pigmentation  is  more  marked  in  syphilitic  than 
in  simple  eruptions.  For  the  pathology  of  this 
staining,  see  chapter  xiv. 

4.  Aberration  from  type. — Whereas  simple  psoriasis 
has  a  decided  tendency  to  aflfect  the  back  of  the 
limbs,  notably  at  the  knees  and  elbows,  the  syphilitic 
form  is  more  often  observed  on  the  flexor  aspect. 

5.  Absence  of  itching  is  the  rule,  but  there  are 
many  exceptions.  It  does  not  depend  upon  the  state 
of  tension  of  the  nerves,  for  there  is  no  certain 
relationship  between  the  amount  of  exudation  and  the 
degree  of  hypersesthesia  of  the  skin.  Either  the 
chemical  products  of  the  inflammatory  changes  are 
but  slightly  irritating,  or  the  poison  of  syphilis  has  a 
sedative  efiect  upon  the  tissue  elements  of  the  nerves. 

iSecondary  and  tertiary  eruptions. — The 
exanthem  of  syphilis,  which  is  rarely  or  never  absent, 
though  frequently  so  slight  as  to  pass  unnoticed  by 


136  Surgical  Pathology.        [Chap. xviii. 

the  patient,  is  a  jjapular  roseola  or  lichen.  The  spots 
vary  from  the  size  of  a  pin's  head  to  the  size  of  a  split 
pea.  The  exudation  is  effused  into  the  papillary  layer 
of  the  skin.  The  rash  generally  makes  its  appearance 
from  the  fifth  to  the  eighth  week  after  inoculation. 
It  is  not  all  thrown  out  at  once,  but  in  an  irregular 
series  ;  whilst  some  spots  are  fading  away  others  are 
formed.  At  this  time  the  joatient  is  somewhat  feverish, 
the  thermometer  recording  a  rise  of  from  one  to  two 
degrees. 

As  before  said,  the  natural  efilorescence  is  often 
modified  by  other  varieties  of  syphilide,  of  which  the 
squamous  is  the  most  common,  whilst  the  vesicular  is 
comparatively  rare.  The  more  severe  the  cutaneous 
lesion,  the  more  likely  is  it  to  assume  the  squamous 
and  tubercular  form.  Though  no  hard  and  fast  line 
can  be  drawn  between  the  secondary  and  tertiary 
manifestations,  it  may  be  said  that  the  former  are  less 
prone  to  suppurate  and  leave  indelible  cicatrices  in 
the  skin.  In  persons  of  pyogenic  tendency,  par- 
ticularly those  of  strumous  diathesis,  destructive 
ulceration  may  commence  quite  early. 

Syphilitic  p§oria,§is.  —  Squamous  syphilide. 
Small  discrete  patches  are  very  frequently  inter- 
spersed with  lichenous  papules  in  the  primary 
eruption.  The  scales  are  less  numerous  and  silvery 
than  in  the  simple  eruption.  In  some  cases  they  form 
a  fine  circlet  at  the  periphery  of  the  spots,  and  are 
thinly  scattered  on  the  surface.  In  others  the  epithelial 
cells,  imbedded  in  fibrinous  exudation,  form  quasi- 
scabs,  which  split  here  and  there,  giving  a  fissured 
appearance. 

Syphilitic  lepra  is  an  inveterate  kind  of 
psoriasis.  It  occurs  in  patients  who  are  broken  down 
in  health,  and  manifest  the  earthy  cachexia ;  hence  it 
is  an  indication  of  profound  constitutional  disturbance. 
It  assumes  a  circular  or  sinuous  outline,  so  common  in 


Chap.  XVIII.]  Syphilis.  137 

syphilitic  affections  of  the  skin.  The  surface  is  more 
or  less  thickly  coated  with  exudative  and  desquamative 
products ;  but  as  the  latter  predominate  it  presents  a 
coarse  scaly  aspect. 

Plantar  and  palmar  psoriasis  is  generally 
of  syphilitic  origin.  As  the  exudation  spreads  beneath 
the  thick  epidermis  it  raises  it,  and  causes  it  to  split 
into  flakes.  The  heel  cuticle,  being  very  dense,  resists 
this  for  some  time,  so  that  it  is  frequently  undermined 
for  a  considerable  distance,  and  when  stripped  off  it 
leaves  a  moist  raw  surface.  Cutaneous  eruption  of 
the  sole  is  at  once  suggestive  of  syphilis  and  scabies, 
the  same  as  ulceration  between  the  toes.  The 
syphilitic  nature  of  palmar  psoriasis  is  often  confirmed 
by  the  existence  of  squamous  patches,  or  superficial 
ulcers  on  the  tongue.  It  is  a  late  secondary  or 
tertiary  symptom. 

Tubercular  syphilide. — The  specific  term  has 
no  reference  to  the  microscopical  anatomy  of  the 
lesion,  as  in  tuberculosis.  It  relates  only  to  the  naked- 
eye  appearance  of  the  eruption.  The  "  tubercles"  are 
firm  hard  nodules  raised  above  the  surface  of  the  skin. 
When  they  form  about  sebaceous  glands  the  disease  is 
known  as  syphilitic  acne.  They  have  a  tendency  to 
ulcerate  ;  but  whether  this  is  developed  or  not,  the 
tissue  elements  are  often  destroyed,  so  that  when  the 
inflammation  subsides  and  the  exudation  and  softeninof 
products  are  absorbed,  pale  depressed  cicatrices  are 
left.  This  is  all  the  more  likely  when  the  eruption 
occurs  in  the  tertiary  stage,  for  then  there  is  less 
probability  of  its  speedy  disappearance.  Histologically 
the  tubercles  consist  of  inflammatory  neoplasia,  without 
any  very  definite  disposition  of  the  constituents.  They 
may  be  considered  as  gummata  in  miniature. 

Bullous  and  vesicular  sypliilides. — Bullous 
eruptions  occur  both  in  acquired  and  congenital  syphilis. 
In  acquired,  as  rupia  ;   in  congenital,  as  pempJiic/us. 


138  Surgical  Pathology.        [Chap. xviii. 

Rujna  is  characterised  by  heapecl-up  incrustations 
on  the  surfaces  of  patches  which  are  usually  occupied 
by  bullae  in  the  first  instance.  The  bulla  bursts  or 
dries  up,  and  the  exudation  and  ej)idermis  form  a  scab, 
which  increases  in  depth  by  addition  to  its  base. 
Meanwhile  the  area  of  inflammation  widens,  and 
consequently  the  scabs  are  somewhat  conical,  and  as 
there  is  more  or  less  lamination  they  resemble  oyster- 
shells. 

Pempliigus. — Children  are  sometimes  born  with  a 
bullous  eruption  upon  them ;  but  most  frequently  it 
appears  after  birth.  In  the  latter  event  it  breaks  out 
within  the  fi.rst  few  days,  or,  what  is  more  usual,  it 
shows  itself  about  the  time  of  the  other  manifestations 
of  cutaneous  syphilis ;  viz.,  from  the  fifth  to  the 
eighth  week.  It  shows  that  the  tissues  and  blood  are 
profoundly  imbued  with  the  poison,  and  betokens  a 
fatal  issue,  very  few  cases  recovering.  "Vesicular 
syphilide  occasionally  constitutes  a  part  of  the  general 
exanthem.  When  it  occurs  late  in  the  disease  it  may 
correspond  with  the  distribution  of  certain  nerves, 
and  then  it  is  probably  the  result  of  syphilitic  peri- 
neuritis. 

Visceral  sypMlis. — Yery  little  is  known  of  the 
visceral  changes  in  the  secondary  stage  of  acquired 
syphilis.  In  the  tertiary  period  they  are  among  the 
best  understood  lesions.  For  the  most  part  they  are 
met  with  as  chronic  inflammatory  thickenings,  and 
lardaceous  degeneration.  The  latter  is  more  likely  to 
develop  when  there  has  been  long-continued  suppura- 
tion, but  it  is  not  confined  to  these  cases.  The  general 
cachexia  is  sufficient  to  account  for  its  occurrence. 
The  abdominal  organs  are  the  chief  seat  of  the  morbid 
process,  especially  the  liver,  kidneys,  and  spleen.  As 
regards  the  essentially  inflammatory  exudations  (e.^., 
in  the  liver)  they  are  met  with  in  four  forms  :  (1) 
gummy  tumours,   (2)   difiuse   interstitial   hyperplasia, 


Chap.  xviiL]  Syphilis.  139 

(3)  capsular  indurations,  (4)  fibrous  bands  or  seams, 
that  divide  the  parenchyma  into  irregular  nodular 
masses  which  simulate  cancerous  projections  ;  but  the 
latter  are  generally  somewhat  umbilicated  in  the 
centre,  whereas  syphilitic  elevations  are  wanting  in 
this  feature.     Syphilis  is  one  cause  of  fibroid  phthisis. 

Intracramal  syphilis  includes  (1)  gummata, 
which  are  generally  found  in  the  cortical  portions  of 
the  brain ;  (2)  chronic  thickening  of  the  meninges 
(pachymeningitis);  (3)  disease  of  the  arteries  {q.r}.\ 
which  may  lead  to  aneurism ;  or  to  thrombosis,  and 
consequent  cerebral  softening.  The  symptoms  to  be 
looked  for  are  severe  continued  headache,  some 
localised  paralysis  or  spasm,  and  double  optic  neuritis. 
Syphilitic  paralyses  {e.g.,  of  the  cerebral  nerves)  are 
for  the  most  part  irregular  and  total. 

luti'aspiiial  sypMlis.  —  Here  also  we  find 
inflammatory  induration,  and  occasionally  gummata. 
Locomotor  ataxy  and  lateral  sclerosis  are  believed  in 
many  cases  to  owe  their  origin  to  syphilis.  The 
peculiarity  of  these  afiections  consists  in  their  being 
to  a  great  extent  confined  to  certain  columnar  systems 
of  the  cord,  in  this  way  contrasting  strongly  with  the 
generally  irregular  distribution  of  tertiary  syphilitic 
lesions.  The  localisation  seems  to  point  to  these 
so-called  "  scleroses  "  being  dependent  on  degeneration 
of  the  nerve -fibres  and  fibroid  substitution,  rather 
than  on  ordinary  infiammatory  exudation.  This  view 
is  further  strengthened  by  the  extremely  chronic 
nature  of  the  morbid  process. 

Syphilis  of  tlie  larynx. — In  the  secondary 
stage  we  meet  with  an  erythematous  condition  as  in 
the  fauces,  mucous  tubercles,  and  sometimes  follicular 
ulcers.  The  inflammation  subsides,  or  it  passes  into 
a  more  obstinate  and  destructive  form,  such  as  arises 
in  the  course  of  other  tertiary  manifestations. 
Tertiary  ulceration  of  the  larynx  usually  begins  at  the 


140  Surgical  Pathology.         [Chap. xviii. 

base  of  the  epiglottis.  It  is  accomj)anied  by  a  good 
deal  of  swelling  in  the  mucous  and  submucous  tissues. 
The  vocal  cords  and  epiglottis  may  be  entirely  eaten 
away.  The  perichondrium  suffers  as  well,  it  may  be 
to  such  an  extent  that  the  cartilao^es  necrose. 

SypMlitic  eye  a^ffectioiiji. — Of  these,  the  one 
of  most  frequent  occurrence  is  iritis,  a  rather  late 
secondary  lesion.  Although  the  disease  is  centred  in 
the  iris  it  involves  other  structures,  e.g.,  the  choroid, 
and  sometimes  the  retina.  The  effused  lymph,  which 
is  in  considerable  quantity,  is  more  lumpy,  and  darker 
in  colour  than  in  simple  iritis.  Permanent  adhesions 
to  the  lens  capsule  (posterior  synechia)  are  liable  to 
form,  and  by  maintaining  a  constant  state  of  tension 
predispose  to  recurrent  attacks  of  inflammation.  The 
natural  hue  and  lustre  are  lost.  The  colour  is  a 
compound  of  the  normal  tint  and  that  of  the  exuded 
reddish  yellow  lymph  ;  so  that  in  a  patient  with  dark 
eyes  it  becomes  a  rusty  brown ;  and  in  one  with  blue 
it  assumes  a  dirty  greenish  appearance. 

Choroiditis  syphilitica  is  characterised  by  dis- 
seminated whitish  patches,  surrounded  by  a  zone  of 
accumulated  pigment.  The  pallor  of  these  spots  is 
due  to  absorption  of  the  epithelial  and  stromal 
pigment,  and  to  the  vascular  exudation.  The  re-deposit 
of  the  colouring  matter  follows  the  general  law  that 
guides  inflammatory  processes  in  highly  pigmented 
tissues,  e.g.,  the  skin.  It  is  not  limited  to  syphilis, 
though  in  it  it  is  unusually  well  marked.  The  subse- 
quent changes  consist  of  atrophy  of  the  choroidal  cells 
and  vessels.  The  retina  is  more  or  less  affected  at  the 
same  time  as  the  choroid,  to  which  it  becomes 
adherent. 

Retinitis  syphilitica  presents  itself  as  a  diffuse 
exudation,  which  extends  from  the  margin  of  the 
optic  disc  in  an  irregular  manner  along  the  course  of 
retinal  vessels.     The  outline  of  the  cloudy  whiteness 


Chap.  XVIII.]  Syphilis.  141 

is  indistinct.  Tliis  disposition  contrasts  strongly  with 
the  brilliant,  highly  refractive  patches  of  albuminuric 
retinitis.  Capillary  haemorrhages  are  not  infrequent. 
The  lymph  is  partly  absorbed,  and  partly  organised 
with  imperfectly  filtrated  tissue.  Meanwhile,  the 
proper  elements  of  the  retina  waste ;  and  the  vessels 
get  smaller  and  smaller,  until  only  a  few  attenuated 
streaks  can  be  seen  traversing  the  optic  disc,  on  their 
way  to  the  fundus.  When  the  atrophy  has  reached 
this  degree  the  disc  is  small  and  pale.  Scattered 
patches  of  choroiditis,  as  above  described,  may  be  seen 
in  different  parts  of  the  f  and  us. 

Double-descending  opHc  neuritis  is  one  of  the 
symptoms  of  intracranial  lesions,  which  are  frequently 
of  syphilitic  origin. 

Congenital  sypliilis. — The  embryo  may  be 
syphilised  from  the  first,  through  one  or  both  parents 
suffering  from  the  disease  at  the  time  of  impregnation. 
Or  the  mother  may  become  infected  during  pregnancy. 
In  either  ease  abortions  are  very  common,  but  they 
are  of  greater  frequency  in  the  former.  The  placenta 
is  often  found  to  be  extensively  diseased,  especially 
the  foetal  portion.  The  chorionic  villi  are  imbedded 
in  inflammatory  exudations,  which  take  the  form  of 
pale  gummatous  consolidations.  This,  together  with 
the  action  of  the  virus  upon  the  developing  tissues, 
causes  the  death  of  the  foetus  and  consequent  abortion, 
which  is  most  common  about  the  third  month  of 
pregnancy. 

Should  the  foetus  survive  until  it  attains  viability, 
it  may  then  be  born  alive  or  perish  in  utero. 

In  the  latter  case  it  generally  shows  unmistakable 
evidence  of  the  disease.  The  skin  is  discoloured* 
The  epidermis  may  be  raised  in  blebs,  or  be  under- 
going desquamation  subsequent  to  bursting  of  the 
bullae  of  what  was  probably  intra-uterine  pemphi- 
gus.    This  must  be  distinguished  from  post-mortem 


142  Surgical  Pathology.        [Chap.  xviii. 

maceration.  When  the  child  is  born  alive,  it  may 
die  immediately  after  birth,  or  within  the  first  few 
days  of  life.  As  a  rule,  however,  nothing  unusual  is 
noticed  until  it  is  from  three  to  eight  weeks  old.  It 
is  noteworthy  that  the  secondary  symptoms  of  con- 
genital syphilis  generally  appear  at  about  the  same 
period  after  birth  as  those  of  the  acquired  disease 
after  inoculation. 

Cutaneous  eruptions. — These  for  the  most 
part  tend  to  be  moist.  They  usually  consist  of  deep- 
red  or  copper-coloured  blotches  upon  the  palms  and 
soles,  and  about  the  anus  and  genital  organs.  Scaly 
and  tubercular  syphilides  are  not  so  well-marked  as 
in  the  acquired  affection.  At  the  same  time,  the  rash 
is  liable  to  be  polymorphous.  Pemphigus  has  been 
referred  to. 

Mucous  tubercles  {loide  Ulcers)  are  very  com- 
mon. They  are  chiefly  found  near  the  verge  of  the 
anus,  in  the  flexures  of  the  groins,  on  the  bucco- 
pharyngeal mucous  membrane,  and  in  the  larynx. 

Affections  of  tlie  mouth  and  nose. — The 
mouth  is  subject  to  diffuse  erythematous  inflammation 
of  the  mucous  membrane.  It  is  also  the  seat  of 
mucous  tubercles  and  superficial  fissured  ulcers,  which 
extend  from  the  angles  to  the  skin  of  the  cheek. 

As  these  heal,  they  leave  radiating  pale  cicatrices 
which  may  persist  throughout  life.  The  faulty  de- 
velopment of  the  permanent  teeth  is  the  result  of 
specific  stomatitis. 

The  mucous  membrane  of  the  nose  is  thickened, 
and  gives  off  a  muco-purulent  discharge.  The  perios- 
teum and  bones  also  suffer,  hence  imperfect  growth 
and  flattening  of  the  bridge.   ( Vide  Diseases  of  bone. ) 

Affections  of  tlie  eye. — (1)  Acute  iritis  is 
more  frequent  than  is  supposed.  It  is  often  not 
observed  because  not  looked  for.  It  is  generally 
symmetrical,  and  occurs  about  the  same  time  as  the 


Chap.  XVIII. 1  Syphilis.  T43 

other  early  secondary  symptoms,  rarely  beyond  the 
sixth  month.  Since  the  anterior  chamber  is  very 
shallow  in  infants,  adhesions  are  liable  to  form  between 
the  lens  capsule  and  the  posterior  surface  of  the 
cornea.  There  may  be  lasting  evidence  of  this  in  the 
shape  of  a  fine  filament  connecting  the  two  structures, 
or  of  a  central  opacity  on  the  front  of  the  lens  capsule 
(pyramidal  cataract) ;  but  this  is  more  common  as  a 
sequel  of  ophthalmia  neonatorum  than  of  congenital 
syphilitic  ii'itis. 

(2)  Interstitial  keratitis  {keratitis  'punctata^  is  a 
tertiary  phenomenon.  Most  common  about  the  age 
of  puberty,  it  attacks  both  eyes,  though  there  may 
be  an  interval  of  several  months.  Lymph  is  deposited 
between  the  corneal  laminse  instead  of  upon  the 
surface.  It  is  first  seen  as  hazy  spots  in  the  substance 
of  the  cornea.  As  these  enlarge,  a  more  diffused 
or  nebulous  appearance  is  presented.  Loops  of  capil- 
lary blood-vessels  form  in  the  exudation  in  connection 
with  the  conjunctival  and  sclerotic  circulation.  As 
the  inflammation  subsides,  the  cornea* clears  up,  first 
at  the  periphery,  then  more  or  less  throughout ;  but, 
as  a  rule,  there  is  a  certain  amount  of  haziness  left, 
and,  in  severe  cases,  very  considerable  opacity. 

Whilst  the  lymph  is  being  absorbed  or  organised, 
the  vessels  shrink  and  finally  disappear. 

(3)  Kerato-iritis  is  an  inflammation  of  the  cornea 
and  iris.  It  is  likewise  a  tertiary  symptom,  making 
its  appearance  from  about  the  fifth  to  the  eighth 
year. 

(4)  Choroiditis  and  retinitis  are  said  to  affect  one 
or  both  eyes  with  about  equal  degrees  of  frequency. 
The  pathology  is  the  same  as  in  acquired  syphilis. 

Affections  of  the  ear.—  Mucous  tubercles  are 
occasionally  seen  in  the  external  auditory  meatus, 
but  they  do  not  lead  to  any  after  results.  Congenital 
syphilis    is    the    most    common    cause    of    permanent 


144  Surgical  Pathology.        [Chap.  xviii. 

double  deafness  in  children.  This  is  du3  to  chronic 
inflammation  of  the  mucous  membrane  of  the  middle 
ear,  and  thickening  of  the  membrana  tympani. 

The  tympanum  is  blocked  with  granulation  tissue, 
which  contracts  and  overcups  the  drum.  Moreover, 
the  ossicles  become  anchylosed,  or  even  absorbed. 

Otitis  media  may  be  accompanied  by  catarrh  of 
the  external  meatus.  This  form  of  ear  disease  is 
liable  to  supervene  on  the  subsidence  of  a  kerato- 
iritis,  but  it  also  occurs  alone. 

Osseous  lesions.    ( Vide  Diseases  of  bone). 

Visceral  lesiosas  consist  of  cono;estive  and 
fibroid  enlargement  of  the  liver,  spleen^  etc.,  and 
gummata.  Swelling  of  the  spleen  is  very  common. 
It  may  be  temjDorary  or  permanent.  The  capsular 
investments  of  the  liver  and  spleen  are  sometimes 
much  thickened.  It  is  said  that  perihepatitis  from 
congenital  syphilis  is  one  cause  of  infantile  jaundice 
and  ascites. 

"  Abscesses "  have  been  described  in  the  lung 
and  thymus  gland.  I  have  seen  a  gumma  in  the 
livsr  of  a  child  twelve  months  old  at  the  time  of 
death.  In  the  brain  one  meets  with  chronic  inflam- 
mation of  the  cerebral  arteries,  meningitis,  and  hydro- 
cephalus from  "  irritative  dropsy  "  of  the  ventricles. 

Oeneral  considerations. — The  secondary  and 
tertiary  symptoms  of  congenital  syphilis  are  more 
frequently  associated  than  in  the  acquired  disease. 
Thus  g-ummata  may  be  met  with  at  a  very  early  age. 
Still,  as  a  rule,  there  is  a  well-marked  interval  between 
the  time  of  disappearance  of  the  rash,  mucous  tuber- 
cles, snuffles,  etc.,  and  the  outbreak  of  graver  lesions, 
such  as  phaged^enic  ulcers,  caries,  and  necrosis  of  bones. 

Considering  that  congenital  syphilis  exerts  its 
morbid  action  on  young  and  growing  tissues,  it  is  not 
to  be  wondered  that  75  per  cent,  of  the  recorded 
cases  of  death  from  syphilis  should  happen  in  children 


Chap.  X1X.J  Rickets.  145 

under  one  year  of  age.  How  profoundly  the  whole 
system  is  steeped  in  the  virus  is  shown  by  the  rapid 
wasting  of  the  body,  and  the  earthy,  cachectic  look 
of  the  skin. 


CHAPTER    XIX. 

RICKETS. 

Ricketis  is  a  constitutional  disease.  Its  chief 
manifestation  is  a  lesion  of  bone  tissue,  occurring  at  a 
time  of  great  developmental  activity.  It  is  looked 
upon  by  some  as  a  symptom  of  scrofula,  but  it  differs 
from  it  by  the  usual  absence  of  other  signs  of  that 
disease,  such  as  suppuration  and  caseation,  and  by  the 
whole  osseous  system  being  affected.  In  some  of  its 
features  it  resembles  congenital  syphilis.^  e.g.,  the 
fibroid  induration  of  parenchymatous  tissues,  such 
as  the  liver,  and  the  enlargement  of  the  epiphyses 
of  bones.  In  fact,  inherited  syphilis  is  considered 
a  cause  of  rickets.  The  balance  of  opinion,  however, 
is  in  favour  of  the  two  diseases  being  distinct. 

Natiu'al  ossification. — To  rightly  understand 
the  morbid  changes  occurring  in  bones  in  rickets,  we 
may  briefly  state  what  takes  place  in  normal  ossifica- 
tion at  the  epiphysis  of  a  long  boue. 

In  a  vertical  section  there  may  be  seen  :  (1)  A 
layer  of  hyaline  cartilage  ;  (2)  a  cartilaginous  matrix 
impregnated  with  lime  salts  forming  trabecular  spaces, 
or  alveoli  which  contain  embryonic  medulla  and 
blood-vessels.  This  layer  constitutes  the  ossiform 
tissue  of  Broca  ;  (3)  true  bone. 

The  cartilage  cells  lodged  in  primary  capsules 
enlarge  and  divide,  and  become  surrounded  by 
secondary  capsules.     A  further  segmentation  occurs, 

K 


146  Surgical  Pathology.  [Chap.  xix. 

and  the  secondary  capsules  undergo  solution ;  broods 
of  embryonic  cells  are  thus  formed,  which  quickly 
join  adjacent  groups  by  absorption  of  the  matrix. 
The  embryonic  tissue  becomes  vascular  by  blood- 
vessels shooting  in  from  the  canals  in  the  true  bone, 
which  latter  increases  by  the  filling  in  of  the  alveoli. 

These  changes  succeed  one  another  so  rapidly  that 
the  intermediate  ossiform  layer  only  attains  a  thickness 
of  about  \\  mm. 

The  growing  part  is  softer  than  cartilage,  and 
hence  gives  way  in  "  fracture  through  the  epiphysis." 

JYSodilied  ossifieatioii  in  rickets.  —  Let  us 
now  look  at  a  similar  section  of  a  rickety  bone.  The 
layer  between  the  cartilage  and  the  bone  is  many 
times  thicker  than  normal.  The  tissue  of  which  it  is 
composed  has  been  termed  spongeoid  by  Guerin,  on 
account  of  its  porosity  and  consistence.  Unlike  the 
healthy  ossiform  layer,  it  is  irregular  in  outline, 
sending  processes  into  the  bone  continuous  with  it. 
It  is  highly  vascular,  and  sometimes  contains  islets  of 
hyaline  cartilage,  partly  explaining  the  isolated  cal- 
cified patches  seen  along  the  line  of  the  epiphyses. 
This  spongeoid  tissue  at  the  surface  joins  with  the 
subperiosteal  osteoid  tissue  of  Yirchow,  which  is 
converted  into  a  soft,  thick,  vascular  substance,  that 
at  a  later  stage  becomes  firmer  and  more  adherent  to 
the  underlying  bone.  The  central  marrow  loses  a 
good  deal  of  its  fat. 

Microscopy. — The  primary  cartilage  capsules  are 
unusually  large,  and  the  secondary  capsules  are  very 
numerous  and  compressed ;  in  fact,  there  is  evidence 
of  greatly  increased  activity  in  the  initial  process  of 
ossification,  whilst  the  later  stages  are  not  only 
delayed,  but  are  for  the  time  abortive. 

Instead  of  the  secondary  capsules  becoming  dis- 
solved, they  are  invaded  by  the  calcifying  process  of 
the  matrix,  and  thus  the  cells  they  contain  are  cut  ofi" 


Chap.  XIX.] 


Rickets. 


147 


from  further  active  change.  They  become  angular, 
are  larger  than  bone  corpuscles,  and  have  no 
anastomatic  canaliculi  (Fig.  H)- 

No  lamination  is  seen  in  the  trabeculse  of  the 
spongeoid  tissue.  The  vascular  channels  of  the  old 
bone  are  continued  into  the  cartilage,  where  they 
enlarge  by  absorption  of  the  calcified  tissue,  and  there, 


Fig.  11. — Zone  of  Proliferating  Cartilage  in  Eachitis. 

a.  Cells  pressed  together  and  stained  brown-violet  with  an  aqueous  solution  of 
iodine,  which  stain  is  due  to  the  glycogenic  matter  they  contain  ;  &,  secondary 
capsule ;  section  made  in  the  fresh  state  and  examined  in  water  (Cornil 
and  Ranvier). 


by  joining  together,  form  a  system  of  intersecting 
canals  filled  with  vascular  embryonic  marroAv.  In 
normal  ossification  the  alveoli  become  occupied  by 
fully  developed  bone  ;  but  in  rickets  there  is  defective 
calcification,  which  occurs  where  it  is  not  wanted,  and 
fails  where  it  is.  The  corpuscles  become  angular,  and 
the  intercellular  substance  finely  fibrillated.  A  similar 
condensation  and  fibrillation  are  noticed  in  the  medulla 
of  the  cancellous  bone,  in  the  Haversian  canals  of  the 
compact  bone,   and    in    the    subperiosteal   formation. 


148  Surgical  Pathology.  [Chap.  xix. 

The  spaces  everywhere  containing  this  medulla  enlai-ge 
by  absorption  of  their  walls,  and  thus,  whilst  the 
constructive  process  falls  short,  the  destructive  is 
actively  at  work,  and  so  the  whole  bone  is  rendered 
soft,  and  is  readily  bent  by  pressure. 

In  the  osteoid  tissue  beneath  the  periosteum 
trabeculse  form,  and  both  in  these  and  the  osteoid 
basis  the  cells  become  stellate  and  anastomatic. 
Immediately  surrounding  the  old  bone  in  the  more 
advanced  stages  are  laminae  of  true  bone,  separated  by 
a  delicate  connective  tissue.  This  appearance  is  due 
to  the  increase  and  subsequent  fibrillation  of  the 
medulla  between  the  laminae,  which  have  been 
attenuated  by  absorption  (Comil  and  Ranvier). 

When  the  morbid  changes  in  the  bones  cease, 
ossification  proceeds  at  a  rapid  rate,  and  at  the  epi- 
physis is  completed  before  the  usual  time,  accounting 
for  the  undue  shortness  of  the  limbs,  since  it  is  chiefly 
by  the  growth  at  the  epiphysial  cartilages  that  the 
bones  increase  in  length. 

Fracture. — The  callus  thrown  out  in  fractures 
of  rickety  bones  consists  of  osteoid  tissue,  and  does 
not  pass  through  the  intermediate  stage  of  cartilage. 
It  is  large,  and  ossifies  readily. 

Deformities. — Even  after  all  morbid  action  has 
ceased  and  ossification  is  completed,  there  is  evidence 
more  or  less  of  the  arrest  of  growth  of  the  bones, 
which,  coupled  with  the  secondary  deformities  from 
pressure,  make  up  the  sum  total  of  a  rickety  skeleton. 
It  is  true,  as  time  goes  on  a  re-moulding  of  the  bones 
takes  place,  so  that  curvatures  partially  or  entirely 
disapjDear.  Where  they  remain  in  the  long  bones,  a 
buttress  of  compact  bone  is  formed  in  the  concavity 
of  the  curve,  acting  as  a  support,  and  so  diminishing 
the  liability  to  fracture.  It  is  not  uncommon  for  a 
long  bone  (e.^.,  the  tibia,  which  is  curved  on  account 
of  its  elongation  from  diffuse  or  general  ostitis)  to  be 


Fig.  12.— Tibia  affected  with 
Eickets. 
a,  Butti'ess  of  compact  hone  support- 
ing tbe  arch  formed  liy  thehenfling 
of  the  shaft,    h.  Small  osteophytes 
(One-third  natural  size.) 


13. — Tibia    affected     with 
Ostitis  Deformans. 

The  sclerosed  bone  is  thiclcer  on  the  convex  than  on  the  concave 
side  of  the  curve.  The  epiphyses  ai-e  hut  little  altered.  The 
curve  was  single— antero-posterior.      (One-third  natural  size.) 


150  Surgical  Pathology.  [Chap.  xix. 

mistaken  for  a  rickety  bone.  A  rickety  tibia  bends 
from  inability  to  sustain  the  weight  of  the  body,  and 
the  fibula  follows  its  curve ;  whereas,  in  addition  to 
this  cause,  an  elongated  tibia  becomes  curved  from  the 
constant  tension  acting  from  the  points  of  fixation  at 
the  ends  of  the  fibula,  the  latter  bone  being  healthy ; 
and  this  is  not  so  much  the  result  of  actual  bending, 
as  re-absorption  of  bone  in  the  concavity,  and  deposit 
along  the  convexity  of  the  curve ;  for,  contrary  to 
rickets,  on  vertical  section  we  notice  the  compact  tissue 
is  much  thicker  in  front  than  behind. 

There  are  other  points  of  difference  which  may 
be  noticed  here  :  the  curve  is  single ;  in  rickets  it  is 
in  two  planes.  The  surface  of  the  bone  is  rough  ;  in 
rickets  smooth.  The  epiphyses  are  not  so  wide, 
perhaps,  as  the  shaft ;  in  rickets  they  are  much 
larger.  The  circumference  of  the  shaft  is  more 
rounded ;  in  rickets  flattened.  The  bone  is  longer 
than  it  should  be ;  in  rickets  shorter.  (Comp.  Figs. 
12  and  13.) 

Fracture  simulated.- — Sometimes,  in  rickets,  when 
the  curvature  is  very  marked  in  the  leg,  the  shaft 
of  the  fibula  is  ossified  to  the  tibia,  simulating  an 
old  badly-set  fracture  of  both  bones.  In  the  latter, 
however,  the  curve  is  less  general  and  uniform,  and 
the  other  signs  of  a  rickety  bone  are  absent. 

Although  in  rickets  the  whole  skeleton  is  affected 
by  the  disease,  the  secondary  deformities  are  more 
marked  in  some  bones  than  in  others,  according  to 
where  the  greater  strain  habitually  falls  ;  and  this,  it 
is  clear,  will  depend  upon  a  variety  of  circumstances. 
If  the  child  lie  much  upon  the  back,  the  occipital 
bone  is  flattened,  and  there  is  a  corresponding  promi- 
nence of  the  forehead  ;  for  the  bones  of  the  cranium 
are  easily  displaced,  since  the  delay  in  ossification 
protracts  the  time  of  closing  of  the  fontanelles  and 
the    fixation    of    the    sutures.        Moreover,    chronic 


Chap.  XIX.]  Rickets.  151 

hydrocephalus  is  by  no  means  infrequently  present, 
and  this  aggravates  the  cranial  deformity.  The  pres- 
sure from  without  and  within  acting  upon  softened 
yielding  bone,  we  see  why  there  is  absorption  here  and 
there  of  the  parietal  and  occipital  bones  (craniotahes). 

In  the  spine  there  is  usually  antero-posterior 
and  lateral  curvature,  with  their  resultant  twisting. 
There  will  be  a  forward  cervical  curve  and  one  large 
posterior  dorso-lumbar  if  the  child  have  been  unable 
to  walk,  the  body  having  been  arched  forwards  from 
want  of  power  of  support ;  or  the  natural  curves 
may  be  simply  exaggerated.  In  some  the  lateral 
curve  is  in  excess  of  the  antero-posterior ;  occasion- 
ally it  is  so  marked  that  one  vertebra  may  eventually 
be  half  an  inch  deeper  on  one  side  than  the  other.  A 
rickety  spine  with  dorsal  curvature  can  be  told  from 
the  kyphosis  of  past  caries  by  its  more  uniform  curve, 
by  the  less  complete  (if  any)  consolidation  of  the 
vertebrae,  and  the  smooth  surface  of  their  bodies. 

It  is  obvious  that  this  alteration  in  the  shape  of 
the  spine  must  entail  a  displacement  of  the  ribs  and 
sternum,  and  so  the  general  conformation  of  the 
chest.  The  sternum  is  thrown  forward  and  keeled, 
and  the  adjacent  part  of  the  rib  cartilages  prominent, 
the  more  so  as  there  is  some  lateral  depression  arising 
from  the  sinking  in  of  the  cartilages  nearer  the  ribs. 

There  is  considerable  thickening  of  the  ribs  at 
their  junction  with  the  cartilages,  giving  rise  to  the 
"  beading,"  and  these  nodes  lying  in  a  curve  on  either 
side  constitute  the  festooned  "  rickety  rose-garland." 
The  down-slanting  of  the  ribs  during  life  must  thrust 
down  the  liver  (frequently  enlarged),  and  so  encroach 
on  the  abdominal  cavity. 

The  pelvis  is  diminished  at  its  inlet,  having 
assumed  a  trefoil  shape  ;  the  weight  of  the  body  dis- 
places forwards  the  promontory  of  the  sacrum  and 
lumbar   vertebrae,   and    the  counter-pressure  through 


152  Surgical  Pathology.         [Chap.  xix. 

the  acetabula  drives  in  those  parts,  A  more  irregu- 
lar deformity,  or  lateral  twisting,  depends  upon  an 
inequality  of  these  forces.  The  femora  show  an 
exaggeration  of  the  forward  and  outward  curves ;  the 
forward,  in  particular,  if  the  child  have  been  carried 
much  with  the  thighs  across  the  arms  of  a  nurse  ;  the 
tibiae  are  curved  forwards,  and  either  inwards  or  out- 
wards ;  the  fibulse  follow  the  tibise.  In  the  upper 
extremity,  we  have  in  the  same  way  to  bear  in  mind 
the  natural  curves  and  the  usual  and  unusual  causes 
and  direction  of  pressure. 

The  joints  are  frequently  distorted,  especially  the 
knees,  in  the  form  of  bandy-leg  or  knock-knee.  This 
is  the  result  of  the  weak  state  of  the  ligaments, 
and  perhaps  also  the  alteration  in  the  shape  of  the 
bones. 

The  milli  teetli  are  cut  late,  owing  to  arrested 
growth,  the  dental  enamel  being  very  deficient.  When 
cut,  they  crack,  and  decay  earlier  than  natural. 

Visceral  cliaiig-es. — The  spleen,  liver,  and  lym- 
phatic glands  may  be  found  indurated,  the  two  former, 
at  the  same  time,  being  sometimes  notably  enlarged. 
The  change  is  dependent  upon  a  general  increase  in 
the  interstitial  tissue. 

The  enlargement  has  been  thought  to  be  due  to 
lardaceous  change ;  but  it  seems  not  to  be  identical, 
for  fibrous  tissue  rarely,  if  ever,  develops  from  the 
albuminoid  substance  found  in  the  same  organs  in 
cases  of  protracted  suppuration,  cancer,  syphilis,  etc.  ; 
and,  further,  the  new  material  in  rickets  is  deficient 
in  earthy  salts  ;  in  lardaceous  disease  it  is  rich  in 
them. 


'53 


CHAPTER   XX. 

TUBERCLE    AND    SCROFULA. 

So  many  different  views  have  been  held  as  to 
the  structure  and  nature  of  tubercle  that  it  is 
impossible  to  give  a  satisfactory  definition.  When 
first  employed,  it  signified  no  more  than  that  in 
certain  diseased  structures  solid  bodies  could  be  seen 
^vith  tolerably  well-marked  naked-eye  appearances. 
No  allusion  was  made  to  microscopical  characters ;  in 
fact,  the  term  was  used  in  a  loose  generic  sense,  with 
a  prefix  to  indicate  its  specific  origin ;  hence  the  ex- 
pressions "scrofulous  tubercle,"  "cancerous  tubercle," 
and  the  like. 

But  later  on  it  received  a  more  restricted  appli- 
cation, and  came  to  be  synonymous  with  the  phrase 
"  anatomical  product  of  scrofulous  inflammation  ; " 
and  to  this  day  the  same  is  understood  in  the  de- 
scription of  many  surgical  diseases,  e.g.^  "  tubercular 
testis,"  "tubercle  of  bone,"  etc. 

Tiiljercle. — The  lungs  of  phthisical  patients 
were,  by  the  older  pathologists,  found  post  mortem  to 
contain  nodules  varying  in  size,  colour,  and  con- 
sistence. These  they  grouped  under  two  heads : 
(a)  minute,  hard,  semi-translucent  bodies^  from  the 
size  of  a  millet  to  a  hemp-seed  {grey  miliary  granula- 
tions) ;  (b)  yellow  caseous  masses,  the  component 
elements  of  which  had  undergone  fatty  metamor- 
phosis (yellow  tubercle). 

Yirchow  proposed  that  the  term  "  tubercle  "  should 
be  limited  to  the  grey  miliary  granulations,  wherever 
found,  whether  in  the  form  of  a  wide-spread  out- 
break,   or    confined    to   the    lungs   as  a  part  of   the 


154  Surgical  Pathology,  [Chap.  xx. 

lesions  of  chronic  phthisis ;  whilst  Bastian  and 
others  hold  that  it  would  be  better  either  to  abolish 
the  term  altogether,  or  reserve  it  only  for  the  cases  of 
acute  general  tuberculosis. 

Histology. — ISTor  has  a  study  of  the  histology 
of  grey  granulations  led  to  any  generally  accepted 
definition.  Thus,  at  one  time  pathologists  were  con- 
tent with  describing  tubercle  as  composed  of  a  reti- 
form  tissue  like  that  of  a  lympliatic  gland  ;  and  the 
more  so,  as  the  grey  granulations  were  mostly  found 
where  lymphoid  tissue  naturally  exists,  e.g.,,  beneath 
the  serous  membranes  and  in  the  parenchyma  of 
many  organs,  notably  the  lungs.  Cornil  and  Kanvier 
assert  that  the  fibrillar  character  of  the  meshwork 
enclosing  the  small  embryonic  cells  is  not  natural,  but 
is  formed  by  the  action  of  re-agents  used  for  harden- 
ing sections,  e.g..,  alcohol.  The  next  step  was  the 
discovery  of  multinucleated  and  multipolar  giant 
cells,  the  outrunners  from  which  freely  unite  with  one 
another  and  with  the  delicate  fibres  of  the  lymphoid 
tissue  in  which  they  are  imbedded.  These  giant  cells 
cannot,  however,  be  held  by  themselves  to  be  charac- 
teristic, since  they  are  not  always  present ;  and  they 
have  been  found  in  other  tissues,  e.g..,  myeloid  sar- 
coma, syphilitic  gummata,  and  the  granulations  of 
simple  ulcers. 

There  can  be  no  doubt  but  that  the  minute  struc- 
ture of  tubercle  is  subject  to  variation.  Thus  it  may 
be  reticular,  or  not ;  it  may  contain  giant  cells,  or 
net.  A  good  deal  depends  upon  the  stage  of  growth 
and  the  extent  of  degeneration. 

The  general  arrangement  is  this  : — The  giant  cells, 
which  may  be  -o^o^h  of  an  inch  in  diameter  and  con- 
tain as  many  as  thirty  or  forty  nuclei,  occupy  the 
centre  of  the  tubercles.  Their  processes  unite  into 
a  fine  net-work  of  themselves,  and  this  is  continuous 
with  that  of  the  adenoid  tissue.     The  adenoid  tissue 


Chap.  XX.]        Tubercle  and  Scrofula.  155 

varies  in  amount,  constituting  the  greater  part  of  the 
tubercle,  or  forming  only  a  narrow  zone  around  the 
giant  cells.  The  alveoli  or  spaces  between  the  fibres 
are  filled  with  small  lymph  cells  (Fig,  14). 

The  whole  is  extravascular,  or  if  vessels  exist  at 
all  they  become  obliterated  very  early. 

The  centre  soon  becomes  caseous  (a  constant 
feature),  and  this  depends  (1)  upon  the  ansemia  of  the 


Fig.  14. — Grey  Granulation  of  the  Liver,  from  a  case  of  Acute 
Miliary  Tuberculosis. 

In  the  centre  of  the  tnhercle  is  a  multinucleated  and  multipolar  giant  cell      Its 
offshoots  join  the  stroma  of  the  retiforui  adenoid  tissue  (6) ;  a,  liver  cells. 

invaded   tissue   caused  by  the  pressure  of  the  over- 
crowding cells,  and  (2)  upon  an  inherent  low  vitality. 
Orig:iii  of  the  lymplioid  or  adenoid  tissues. 

— Whether  it  be  an  irritative  overgrowth  of  pre- 
existing adenoid  tissue,  as  seems  probable,  from  the 
tendency  for  tubercle  to  a^Dpear  at  the  seats  of  natural 
distribution  of  the  former ;  or  a  mere  inflammatory 
exudation  which  organises  on  the  adenoid  type,  is  not 
certain,  and  is  of  little  moment. 


156  Surgical  Pathology.  [Chap.  xx. 

Origin  of  the  giant  celts. — According  to  Klein, 
they  start  from  the  epithelial  cells  of  the  alveoli  in 
the  case  of  the  Inng,  either  by  fusion  of  the  protoplasm 
of  contiguous  cells,  or  by  the  continuous  growth  and 
arrested  segmentation  of  individual  cells.  Another 
source  is  said  to  be  the  epithelioid  lining  of  the 
lymphatics  and  even  of  the  blood-vessels. 

It  may  be  remarked  that  caseation,  formerly  con- 
sidered as  characteristic  of  tubercle,  is  not  confined  to 
that  morbid  product,  but  occurs  wherever  the  vitality 
of  a  tissue  is  slowly  impaired,  especially  in  scrofulous 
inflammations,  and  notably  in  the  case  of  bone,  testicle, 
lymphatic  glands,  and  in  the  lungs  of  patients  the 
subjects  of  catarrhal  pneumonia.  Again,  it  is  well 
marked  in  syphilitic  gummata,  and  in  quickly  growing 
tumours  such  as  sarcoma  and  cancer,  where  the  pro- 
duction of  cells  outstrips  the  development  of  blood- 
vessels. In  all  these  instances  the  elements  undergo 
fatty  atrophy  from  slow  starvation. 

Oemeral  patliology  of  tutoercle. — 1.  Infec- 
tive origin. — Without  doubt  tubercle  arises  from 
infection ;  that  is  to  say,  it  is  the  product  of  irritation 
of  the  tissues.  The  irritant  consists  for  the  most  part 
of  the  debris  from  some  caseous  focus,  as  a  scrofulous 
gland  or  carious  bone.  But  the  results  of  artificial 
inoculation  of  the  lower  animals  show  that  whilst  this 
material  is  more  potent  than  any  other  (Sanderson),  it 
is  not  essential.  Thus  in  guinea-pigs  tubercle  can  be 
induced  by  inserting  a  simjjle  seton  into  the  sub- 
cutaneous cellular  tissue.  The  products  of  the  local 
inflammation  are  carried  by  the  lymphatics  and  blood- 
vessels, and  set  up  secondary  changes  in  various  parts 
of  the  body. 

It  is  a  significant  fact  that  in  most,  if  not  all,  the 
instances  of  tuberculosis  in  the  human  subject,  a 
collection  of  caseous  matter  can  be  found.  It  may  be 
situated    in    the    immediate    neighbourhood    of    the 


Chap.  XX.]       Tubercle  and  Scrofula.  157 

tubercular  deposit,  as  when  a  caseous  pneumonia  is  the 
starting  point  of  pulmonary  tubercle  ;  or  the  source  of 
infection  may  be  more  remote.  I  have  known  tuber- 
cular meningitis  arise  from  strumous  inflammation  of 
the  OS  calcis. 

At  the  present  time  attention  is  being  directed  to 
the  investigation  of  tubercle  infection,  and  especially 
as  to  its  dependence  upon  a  microscopical  organism 
(bacillus). 

Before  this  point  can  be  satisfactorily  settled,  it 
must  be  shown  that  the  bacillus  is  invariably  present, 
and  that  it  is  the  cause  and  not  the  consequence  or  coin- 
cidence of  tubercular  inflammation.  If  these  alleged 
facts  be  established,  they  will  go  far  to  dispel  the 
theory  of  '•  caseous  infection,"  for  it  seems  improbable 
that  a  living:  ora:anism  should  be  dormant  for  months 
or  years,  and  then,  without  any  recognisable  cause, 
start  into  active  life. 

2.  Disposition  of  the  tissues  affected. — It  must 
be  allowed  that  there  is  something  more  than  a  mere 
local  irritation.  There  is  a  tendency  in  the  tissues 
themselves  to  undergo  a  special  modification  of  nutri- 
tion (dyscrasia),  just  as  in  the  specific  fevers  the 
poison  of  each  "  selects "  one  or  more  parts  for  its 
local  manifestation;  in  typhoid  it  is  the  mucous  mem- 
brane of  the  alimentary  canal;  in  diphtheria,  the 
throat.  But  there  is  this  difference,  that  whereas 
tubercle  usually  arises  spontaneously  or  is  autogenetic, 
the  specific  fevers  always  depend  upon  infection  from 
without. 

3.  Tubercle  compared  with  pycemia. — In  some 
respects  tubercle  resembles  pysemia,  especially  in  its 
mode  of  production,  and  more  particularly  in  that 
form  where  it  is  artificially  induced  by  exciting  local  in- 
flammation. But  the  contrasts  are  many  and  important. 
Thus,  in  tubercle  there  is  (a)  the  absence  of  embolic 
infarction  and  abscess ;  (&)  the  greater  chronicity  of 


158  Surgical  Pathology.  [Chap. xx. 

its  course ;  (c)  comparatively  little  tendency  to  rapid 
softening  of  the  disseminated  products ;  {d)  the  un- 
doubted fact  of  hereditary  taint;  or,  in  other  words,  the 
transmitted  tendency  to  scrofulous  inflammation. 

Scrofula. — A  patient  is  said  to  be  scrofulous 
when  he  is  subject  to  chronic  inflammations  of  a  low 
type,  inflammations  that  arise  without  an  adequate 
local  cause,  and  show  a  tendency  to  persist  and  progress. 
The  evidence  of  a  low  vital  condition  of  the  tissues 
is  strengthened  by  the  changes  that  occur  in  the 
inflammatory  exudation.  This  is  prone  to  undergo 
a  slow  fatty  degeneration  and  caseation  rather  than 
organisation.  The  older  pathologists  termed  the 
lymph  in  such  cases  "  aplastic,"  in  contradistinction 
to  that  efi'used  under  a  more  healthy  state  of  the 
constitution.  That  there  is  a  "  scrofulous  diathesis  " 
in  the  sense  of  a  specific  materies  morbi  in  the  blood 
is  improbable.  All  we  can  say  with  certainty  is  that 
there  is  a  weakness  of  the  tissues,  an  instability  that 
renders  them  unable  to  resist  the  ordinary  causes 
of  inflammation  and  to  rally  for  repair.  ISTo  doubt 
in  many  cases  it  is  hereditary,  but  not  in  the  sense  of 
a  specific  transmission  of  disease  as  in  syphilis,  but  as 
a  repetition  of  a  morbid  condition  of  tissue,  just  as 
in  any  other  simple  disorder  of  nutrition. 

Besides,  the  child  may  be  born  strong,  and  of 
healthy  parents,  and  yet  afterwards  become  strumous 
through  exposure  to  bad  hygienic  conditions.  From 
the  above  statements  it  follows  that  we  should  meet 
with  every  degree  of  scrofula,  from  slight  affection  of 
one  tissue  to  the  serious  implication  of  many ;  and 
hence  there  is  no  reason  for  discarding  the  term 
simply  because  the  local  signs  of  the  disorder  are  not 
more  pronounced. 

There  are  some  cases  of  disease  of  bones  and 
joints  which  no  surgeon  would  hesitate  to  speak  of 
as  scrofulous,  and  yet  several  authors  argue  that  the 


Chap.  XX.]        Tubercle  and  Scrofula.  159 

milder  types  of  these  affections  are  not  of  this  nature  ; 
a  false  conclusion,  wo  think,  for  between  the  most 
destructive  form  of  caries  and  the  mildest  case  of 
non-traumatic  rarefying  ostitis  there  is  every  grade  of 
severity.  And,  again,  the  less  severe  the  lesion,  the 
less  likely  it  is  to  show  itself  in  several  parts  of  the 
body.  The  difficulties  in  the  way  of  clearly  defining 
scrofula  and  tubercle  and  their  mutual  relationships 
have  led  some  pathologists  to  evade  the  question 
by  denying  the  scrofulous  nature  of  hip-joint  disease 
and  allied  disorders. 

The  old  idea  that  "  tubercle  is  the  anatomical 
product  of  scrofulous  inflammation,"  in  spite  of  all 
drawbacks,  still  remains  the  simplest  and  most  com- 
prehensive explanation  of  the  disease. 

According  to  this,  the  term  "  tubercle "  includes 
every  phase  of  the  inflammatory  exudation,  whether 
this  be  in  the  form  of  diffuse  gelatinous  tissue,  or 
grey  miliary  granulations,  or  either  of  these  converted 
into  yellow  caseous  matter  by  fatty  degeneration  ; 
take,  e.^.,  the  testis  or  bone.  On  anatomical  grounds 
it  would  be  better  to  describe  miliary  tuberculosis 
apart  from  diffuse  chronic  inflammation,  but  for  the 
fact  that  they  are  often  associated,  and  not  merely 
by  accident,  for  they  depend,  directly  or  indirectly, 
upon  the  same  constitutional  condition  ;  e.g.^  a  child 
had  strumous  inflammation  of  the  os  calcis,  and  in 
the  diseased  bone  neither  giant  cells  nor  retiform 
adenoid  tissue  could  be  found ;  but  it  died  from  an 
acute  outbreak  of  miliary  tuberculosis  in  the  lungs, 
pleurae,  and  pia  mater.  It  is  certain  that  grey  granula- 
tions are  met  with  in  the  bones  and  testes,  but  in  by 
far  the  greater  number  of  cases  described  as  tubercular 
disease  of  these  tissues,  there  is  nothing  more  than 
the  products  of  simple  inflammatory  exudation. 

We  are  inclined  to  use  the  word  scrofula  in  a  gen- 
eric sense  descriptive  of  the  constitutional  condition, 


i6o  Surgical  Fathology.  [Cnap.  xx. 

and  to  speak  of  its  products  under  two  lieads  :  (I) 
the  primary  essential  inflammatory  exudation  which 
may  exist  alone,  or  be  followed  by  (2)  secondary 
infective  miliary  tubercle.  In  some  individuals  there 
is  a  strong  tendency  to  the  development  of  the  latter, 
whilst  in  others  the  tissues  are  destroyed  by  scrofulous 
inflammation  extending  over  months  or  years  without 
giving  rise  to  a  single  grey  granulation. 

Scrofulous  inflammations  are  peculiarly  liable  to 
end  in  suppuration  and  caseation,  either  singly  or 
more  often  in  combination. 

Tissues  affected. — The  parts  most  prone  to  be 
aflected  are,  the  skin,  mucous  membranes,  bones, 
joints,  testes,  lymphatic  glands,  and  the  lungs. 

In  the  skin  we  meet  with  (1)  simple  catarrh,  or 
eczema ;  (2)  limited  superficial  ulceration ;  (3)  wide- 
spread ulceration.  In  some  cases  there  is  extensive 
undermining  from  destruction  of  the  subcutaneous 
cellular  tissue.  The  skin  becomes  purple  and  con- 
gested in  parts  from  obliteration  of  the  lumen  of  the 
vessels  that  feed  it.  This  form  is  exceedingly  ob- 
stinate, and  leaves  thin  broad  cicatrices. 

Catarrhal  inflammation  and  ulceration  of  the 
mucous  membrane  of  the  nose  is  very  common.  It 
causes  snuffling  and  offensive  discharge  (ozoena).  It 
is  most  marked  at  the  back  of  the  nasal  fossae.  Some- 
times it  extends  to  the  soft  palate,  which  may  be 
fenestrated  by  ulceration. 

Children  are  very  liable  to  catarrhal  ophthalmia, 
and  also  to  pustular  conjunctivitis  and  phlyctenular 
corneitis.  These  aflfections  are  apt  to  recur  again  and 
again. 

Scrofulous  inflammation  of  the  hones  may  only  go 
so  far  as  to  cause  a  rarefying  ostitis  without  suppura- 
tion (caries  fungosa),  but  more  often  pus  is  freely 
formed.  The  bone  is  destroyed  by  the  carious  pro- 
cess, and  it  may  be  by  necrosis  as  well.    The  cancellous 


Chap.  XX.]        Tubercle  and  Scrofula. 


i6i 


tissue  is  the  favourite  situation;  e.g.,  the  vertebrae, 
ends  of  the  long  bones,  carpus  and  tarsus. 

Strumous  disease  of  the  joints  commences  either 
in  the  synovial  membrane  or  in  the  bone. 

In  '■^strumous  or  tubercular  orchitis"  the  epididymis 
is  first  afiected ;  both  organs  usually  suffer  sooner  or 


Fig.  15.— Chronic  Interstitial  Epididymitis  (Scrofulous  Testicle). 

a,  Intertubular  tissue  thickened  and  infiltrated  with  leucocytes;  the  vessels,  c, 
ai'tiflcially  injected;  6,  epithelium  lining  tubules;  cJ,  epithelium  m  process 
of  disintegration. 


later.  The  inflammation  begins  between  the  tubules 
(Fig.  15).  Caseation  and  suppuration  are  common. 
The  cord  is  thickened.  The  vesiculse  seminales  may 
be  enlarged. 

Of  the  lymphatic  glands,  the  submaxillary,  cervical, 
mesenteric,  and  bronchial  take  the  lead.  The  disease 
is  rarely  limited  to  one  gland.  It  may  lead  to  fibrous 
induration,  but  more  likely  to  caseation  and  abscess. 
In  the  event  of  suppuration,  the  sores  are  slow  to  heal, 
and  leave  indelible  scars  in  the  skin.     In  the  neck 


i62  Surgical  Pathology.  [Chap.  xxi. 

they  cause  great  deformity.  Scrofulous  inflammation 
of  the  mesenteric  glands  is  kno^^ii  as  "tabes  mesen- 
terica. " 

In  the  lungs  the  greater  part  of  chronic  phthisis 
is  a  scrofulous  catarrhal  pneumonia. 

Period  of  life. — Scrofula  is  most  common  in 
childhood  and  youth,  but  no  age  is  exempt.  Those 
who  have  had  scrofulous  glands,  or  bones,  or  joints  in 
their  earlier  years,  often  die  of  phthisis  at  a  later  period. 

Sir  J.  Paget  has  described  a  senile  scrofula  of  the 
bones,  joints,  and  other  parts,  in  which  the  patho- 
logical changes  closely  correspond  to  strumous  disease 
of  young  subjects.  It  may  be  that  such  patients  had 
an  undeveloped  tendency  to  scrofulous  inflammation 
in  childhood,  but  that  it  only  showed  itself  in  old  age, 
when  senile  decay  was  added  to  the  original  weakness 
of  the  tissues. 


CHAPTER  XXL 

LUPUS. 

Lupus  is  probably  a  disease  jf:>er  se.  The  family 
and  ])ersonal  history  show  it  to  be  more  often 
associated  with  scrofula  than  any  other  morbid  state. 
Some  authors  describe  it  as  one  of  the  symptoms  of 
scrofula ;  but  as  it  is  frequently  the  only  visible  lesion, 
and  as  most  scrofulous  subjects  are  free  from  it,  we 
are  justified  in  assuming  that  it  is  modified  rather 
than  caused  by  scrofula.  It  manifests  itself  in  a 
peculiar  form  of  chronic  inflammation  of  the  skin  and 
mucous  membrane.  It  is  sometimes  hereditary.  It  has 
a  special  proclivity  for  the  first  two  decades  of  life. 
Its  course  and  duration  are  alike  indefinite.  The  face 
is  its  favourite  seat,  but  it  is  by  no  means  confined  to 


Chap.  XXI.]  Lupus.  i6 


«) 


that  part.  It  also  attacks  the  mucous  membrane  of 
the  mouth,  nose,  and  eyelids,  and  usually  by  spreading 
from  the  skin.  Several  forms  are  described,  but  these 
ai'e  modifications  of  a  common  type,  and  not  distinct 
varieties.  If  the  hypersemia  be  in  marked  contrast  to 
the  degree  of  destruction  of  tissue  it  is  called  lupus 
erythematosus ;  if  the  disease  go  on  to  ulceration 
it  is  known  as  lupus  exedens ;  if  it  stop  short  of  this, 
lupus  non  exedens  ;  if  the  ulceration  be  rapid  and 
extensive,  the  word  vorax  is  affixed,  and  so  on. 

It  begins  as  a,  small  red  inflammatory  nodule  or 
thickening  in  the  skin.  This  may  disappear,  and 
others  form,  or  it  may  continue  to  enlarge.  There 
are  usually  several  outlying  tubercles,  and  as  these 
increase  in  size  they  join  one  another  and  the  central 
growth..  The  exudation  is  firm,  and  to  the  unaided 
eye  looks  like  "  apple-jelly,"  an  appearance  which  is 
due  to  mucoid  transformation  of  the  inflammatory 
products.  Some  suppose  that  capillary  thrombosis 
precedes  the  other  changes,  but  it  is  difficult  to  say 
how  far  it  is  the  cause  or  consequence  of  the 
inflammation.  Tlie  microscope  reveals  a  decided 
overgrowth  of  epithelium,  both  on  the  surface  and  in 
the  glandular  involutions ;  and  an  infiltration  with 
leucocytes  and  homogeneous  gelatinous  material. 

The  exudation  on  the  surface  dries  up  and  forms 
an  adherent  scab,  or  it  escapes  as  a  purulent  discharge ; 
in  the  latter  case  the  skin  is  as  a  rule  ulcerated.  As 
the  inflammation  subsides  in  the  older  parts,  there  is 
a  tendency  to  cicatrise,  to  a  greater  extent  than  in 
rodent  ulcer,  but  less  than  in  tertiary  syphilis. 

But  whilst  the  central  part  is  healing,  the  peri- 
pheral may  continue  to  spread,  and  in  this  way  very 
extensive  thin  cicatrices  may  be  formed.  Whether 
there  be  ulceration  or  not,  there  is  always  loss  of 
tissue,  and,  as  a  consequence,  a  certain  amount  of 
pitting  or  depression  of  the  surface. 


t64  Surgical  Pathology.         [Chap.  xxii. 

Ulcerative    lupus,    lupus    exedens.  —  The 

tendency  of  lupous  ulceration  is  to  spread  widely, 
rather  than  deeply;  but  there  are  exceptions  to  the 
rule.  The  enlarged  papillae  are  exposed,  and  then 
destroyed,  and  with  them  the  glandular  structures. 
In  the  more  severe  forms  there  is  considerable  secre- 
tion of  pus,  and  molecular  debris  of  the  neoplasia. 
In  these  cases  the  edges  are  sharply  defined,  and  the 
skin  around  is  deeply  congested,  and  the  pain  is  often 
severe.  Cicatrisation  goes  on  slowly,  for  the  inflam- 
matory new  formation  has  little  power  of  organising. 
That  there  is  something  peculiar  in  the  nature  of  the 
morbid  products  is  shown  by  the  comparative  readiness 
with  which  simple  irritative  exudation,  caused  by  the 
means  taken  to  destroy  the  lupus  tissue,  forms  healthy 
granulations.  The  ulcers  are  mostly  circular  or  sinuous 
in  outline.  There  may  be  one  or  more.  The  cheek, 
the  nose,  and  the  eyelids  are  the  parts  most  affected. 
The  treatment  consists  essentially  in  the  removal  of 
the  diseased  tissue  by  caustic,  or  better  still  by  scraping 
or  scarification.  After  the  wound  has  completely 
healed  fresh  tubercles  are  very  likely  to  spring  up  in 
the  neighbourhood  of  the  scar,  and  then  the  whole  pro- 
cess is  repeated,  unless  checked  by  surgical  interference. 
When  it  attacks  the  face  the  ulceration  is  usually 
confined  to  the  skin,  subcutaneous  tissue,  and  cartilages 
of  the  nose;  but  the  bones  may  be  extensively  affected. 


CHAPTER  XXII. 

TETANUS. 

Tetanus  is  characterised  by  tonic  contractions  of 
the  muscles,  commencing  about  the  face  and  neck  and 
spreading  to  the  trunk  and  extremities. 


Chap.  XXII.]  Tetanus.  165 

Etiology  and   general  pathology. — In  the 

majority  of  cases  tetanus  arises  in  connection  with 
wounds,  especially  those  of  the  limbs.  The  liability 
to  the  disease  is  in  no  way  dependent  on  the  severity 
of  the  injury ;  in  fact,  it  is  remarkable  that  in  many 
instances  the  most  acute  onset  and  progress  follow  the 
slightest  scratch.  In  hot  climates  it  is  often  idio- 
pathic. Some  consider  that  traumatic  tetanus  is  due 
to  irritation  of  the  nerves  implicated  in  the  wound, 
and  that  the  muscular  spasms  result  from  reflex 
irritation.  In  support  of  this  view  is  the  statement 
that  an  attack  has  now  and  then  been  cut  short  by 
division,  or  stretching  of  the  nerves  supposed  to  be  at 
fault ;  but  some  cases  recover  without  treatment, 
whilst  the  greater  number  die,  whatever  is  done  for 
them.  I  once  stretched  the  median  and  radial  nerves  in 
a  patient  whose  thumb  and  fore-finger  had  been  crushed 
by  an  engine-wheel ;  but  witliout  the  slightest  benefit. 
The  evidence  in  favour  of  its  being  a  blood  disease 
seems  very  strong. 

(1)  It  is  greatly  dependent  on  climatic  influences, 
and  is  sometimes  epidemic,  though  there  is  no  proof 
that  it  is  contagious. 

(2)  The  resemblance  to  strychnia  poisoning,  and 
still  more  to  hydrophobia,  is  well  marked, 

(3)  The  spasms  commence  in  muscles  having  no 
anatomical  connection  with  the  injured  nerves. 

(4)  Some  cases  arise  spontaneously. 

It  is  true  the  nerves  have  been  found  more  or  less 
locally  congested  and  inflamed,  but  this  must  happen 
in  all  cases  of  wounds.  I  failed  to  find  anything  unusual 
in  the  median  nerve  in  the  case  hereafter  stated. 

Condition  of  tlie  spinal  cord.  —  Clifford 
AUbutt  and  others  have  described  certain  oro:anic 
changes,  which  in  the  main  consisted  of  structureless 
exudation,  and  hyperplasia  of  the  neuroglia.  Cornil 
and  Kanvier  failed  to  detect  anything  abnormal.      Of 


i66 


Surgical  Pathology. 


[Chap.  XXII. 


four  cases  examined  by  myself,  two  were  to  all 
appearance  quite  healthy ;  the  third  was  simply  con- 
gested; this  might  have  been  from  asphyxial  death;  the 


Eig.  16. — Transverse  Section  of  Spinal  Cord  (cervical  region),  from  a 
case  of  very  acute  Tetaniis.  A  portion  of  one  of  the  anterior  cornua 
of  the  grey  matter,  with  the  surrounding  antero-lateral   column, 

is  seen. 
a,  Pia  mater;  J,  anterior  white  column  traversed  by  hundles  of  fibres  going  to 
form  anterior  root  of  spinal  nerve  ;  c,  grey  matter  ;  d,  blood-vessels  ;  e,  patches 
of  exudation  and  softening,    x  85. 


fourth  is  represented  by  Fig.  16.  The  entire  spinal 
cord,  medulla  oblongata,  pons,  and  cerebellum  (the 
cerebrum  was  not  examined),  were  thickly  strewn 
with  patches  easily  visible  to  the  naked  eye.  They 
were  most  numerous  in  the  cervical  part  of  the  cord. 
They  were  readily  stained  with  logwood  and  carmine. 
Under  the  microscope  they  appeared  as  roundish 
homogeneous  masses,  distributed  equally  in  the  grey 
and   white   constituents  of  the   centres.      The  nerve- 


Chap.  XXIII.] 


Tetanus. 


167 


fibres  were  in  some  places  pushed  aside  by  the  exuda- 
tion, in  which,  at  the  margin  of  the  foci,  delicate 
fringes  of  softening  tissue  were  seen  to  be  imbedded 
(Fig.  16a).  There  was  moderate  congestion.  The 
perivascular  lymphatic  sheaths  were  in  some  places  dis- 
tended with  a  clear  substance.     There  was  singularly 


^^#!f<^^>,<^:'(0^  I'^^^^^y 


Fig.  16a.— Portion  of  Fig.  16,  x  260. 

a,  MeduUated  flhres  in  cross  section  ;  6,  focus  of  softening  :  the  nerve  fl^bres  and 
neuroglia  completely  absorbed  in  the  centre ;  c,  exudation  into  perivascular 
lymphatic  sheatli ;  d,  anterior  cornual  fibres. 

little  cell-migration.  The  motor  ganglion  cells  were 
healthy.  The  patient,  a  negro  boy,  cat.  11,  under  the 
care  of  Mr.  Boon,  of  St.  Kitts,  had  a  gun-shot  fracture 
of  the  left  humerus,  and  laceration  of  the  median  nerve. 
Tetanus  appeared  on  the  seventh  day,  and  death  oc- 
curred on  the  tenth.  The  spasms  were  chiefly  confined 
to  the  right  side  of  the  body.  Sections  of  the  median 
nerve  an  inch  above  the  seat  of  injury  showed  nothing 
abnormal. 


CHAPTER     XXITL 

UNION    OF    WOUNDS. 

Modes  of  union.— 1.  By  first  intention  or  plas- 
tic adhesion.    2.    By  open  granulation.    ( Vide  Healing 


1 68  Surgical  Pathology.        [Chap, xxiii. 

nicer.)       3.  By   the    union    of    opposed    granulating 
surfaces.      4.   By  scabbing. 

There  is  no  such  thing  as  immediate  union,  for 
however  perfectly  the  edges  of  a  wound  are  brought , 
together,  it  is  impossible  for  the  open  ends  of  the 
divided  vessels  to  meet  so  accurately  as  then  and  there 
to  re-establish  the  lumen.  Besides  this,  the  irritation 
caused  by  the  injury  sets  up  thrombosis  in  the  mouths 
of  the  vessels,  and  the  coagula  must  be  absorbed  before 
healing  is  complete. 

1.  Healiog-  t>y  Urst  iiitention. — Take,  e.g.,  a 
simple  incised  wound  in  the  skin  and  subcutaneous 
tissue.  The  edges  of  the  wound  gape  on  account  of 
the  elasticity  of  the  skin.  Bleeding  takes  place  from 
the  divided  vessels  until  arrested  by  the  formation  of 
clots.  It  usually  stops  of  itself,  for  exposure  leads  to 
spontaneous  coagulation  of  the  blood,  and  the  vessels 
shrink  from  contraction  of  their  muscular  elements, 
and  retract  somewhat  within  their  sheaths  or  bed  of 
areolar  tissue.  On  wiping  the  clot  away  from  the 
wound,  its  small  w^orm-like  processes  occupying  the 
ends  of  the  vessels  are  often  drawn  out,  whereupon 
the  bleeding  recommences.  It  is  immediately  arrested, 
however,  if  the  sides  of  the  wound  be  brought  together. 
There  is  now  a  thin  layer  of  blood  between  the  cut 
surfaces,  and  thrombi  fill  the  vessels  for  a  short 
distance  around.  Very  soon  a  faint  blush  is  observed 
at  the  margin  of  the  wound,  fading  away  into  the 
healthy  tissue.  The  visible  redness,  which  is  due  to 
paralysis  of  the  vessels  consequent  on  the  injury,  is  an 
indication  of  a  like  condition  in  the  deeper  parts. 

Hxuclatioii  stage. — Leucocytes  infiltrate  the 
tissues  and  collect  in  the  space  between  the  divided 
surfaces,  first  occupying  and  then  replacing  the  clot, 
which  liquefies,  and  undergoes  absorption.  By  this 
time  there  is  slight  tumefaction  of  the  part,  and  the 
line    of    incision    is    covered    with    a    film    of    fibrin 


Chap.  XXIII.]  Union  OF   Wounds.  169 

entangling  blood  corpuscles.  In  the  meanwhile,  the 
connective  tissue  becomes  swollen,  and  its  fibres  less 
defined.  As  the  inflammation  subsides,  the  vessels 
regain  their  former  calibre ;  numbers  of  leucocytes 
break  up  from  fatty  degeneration,  and  the  debris  is 
taken  up  by  the  capillaries,  whilst  others  remain  to 
take  part  in  the  process  of  cicati'isation.  As  yet,  the 
blood-vessels  and  lymphatics  are  blocked  on  each  side 
of  the  column  of  leucocytes  lying  between  the  side 
walls  of  the  incision.  The  blood  clot  has  disappeared, 
and  the  wound  to  all  external  appearance  has  healed, 
for  at  the  end  of  two  or  three  days  there  is  well- 
marked  cohesion  between  its  edges.  The  firmness  of 
the  part  is  due  to  the  condensation  of  plastic  lymph 
(fibrin),  that  glues  the  inflammatory  cells  together. 

Tasciilarisation  of  tlie  neoplasia. — Loops 
and  buds  are  given  oflT  from  the  vessels  surrounding 
the  wound,  mainly  in  a  direction  at  right  angles  to 
the  latter.  These  approach  from  opposite  sides,  and, 
meeting  midway,  join  by  absorption  of  their  contiguous 
walls.  It  is  also  possible  that  there  is  a  free  vascular 
new  formation  in  the  exudation,  especially  when  there 
is  a  considerable  tract  of  cells.  In  the  meanwhile, 
the  inflammatory  corpuscles  elongate.  The  wound  is 
now  united  by  vascularised  lymph  or  granulation 
tissue,  the  capillaries  of  which  are  larger  and  more 
numerous  than  in  the  surrounding  structures. 

Cicatrisatioii. — The  fusiform  granulation  cells 
remain  as  connective  tissue  corpuscles.  The  inter- 
cellular substance  fibrillates  and  contracts,  and  con- 
tracting obliterates  many  of  the  vessels ;  nor  does  this 
cease  until  the  scar  is  firmer  and  whiter  than  the 
normal  tissue.  Numbers  of  cells  also  disappear 
through  atrophy  from  chronic  starvation.  If  the 
adaptation  of  the  edges  of  the  wound  have  been 
accurate,  and  union  unimpeded,  the  scar  may  entirely 
vanish  in  time. 


lyo  Surgical  Pathology.        [Chap.  xxiii. 

Failure  of  imion  is  brought  about  by  any  cir- 
cumstance that  adds  to  the  necessary  amount  of  trau- 
matic inflammation.  1.  Poisoning  of  the  wound,  as 
in  post-mortem  cuts.  2.  Mechanical  obstacles  to  close 
apposition  of  the  edges  ;  {a)  presence  of  foreign  bodies 
or  large  blood-clots ;  (6)  tension  on  the  supports  from 
muscular  contraction,  etc.  3.  Bruising  of  the  edges 
at  the  time  the  injury  was  inflicted,  or  subsequent 
irritation. 

Mealiiag:  toy  graiiMlatioii.  —  There  is  no 
essential  factor  in  this  mode  of  healing  that  was  not 
found  in  union  by  the  first  intention.  The  difierence 
is  one  of  degree  and  disposition  rather  than  of  kind. 
Taking  the  case  of  an  incised  wound,  where  the 
edges  are  allowed  to  gape,  the  following  signs  are 
observed. 

Firstly,  there  is  bleeding,  which  continues  until 
the  blood  coagulates  in  the  open  vessels  up  to  the 
next  collateral  branches.  Then  follow  inflammatory 
hypersemia  and  exudation.  The  transuded  fluid  is  so 
rich  in  fibrin  that  it  gelatinises  on  the  surface,  giving 
it  a  glazed  appearance.  But  about  the  second  day  the 
exudation  is  too  copious  to  be  retained  within  the 
interstices  of  the  tissues  and  on  the  surface  of  the 
wound ;  it  therefore  flows  away  as  a  pink  serous 
fluid,  the  colour  of  which  is  due  to  suspended  red 
blood-corpuscles  and  dissolved  hsemogiobin.  In  a 
short  time  the  discharge  alters  to  a  dirty  yellowish- 
gray,  in  consequence  of  a  greater  proportion  of  pus 
cells,  and  the  granular  or  flocculent  debris  of  tissue 
elements  that  have  died  from  the  embarrassment  of 
the  circulation  in  the  superficial  layer.  It  passes 
insensibly  into  a  genuine  suppuration;  but  before 
the  latter  is  quite  established,  the  wound  has  under- 
gone a  decided  alteration ;  small  bright  red  elevated 
spots  have  made  their  appearance.  These  are  inflam- 
matory   granulations,    or  groups    of  cells  heaped  up 


Chap.  XXIII.] 


Union  of   Wounds. 


171 


around  festooned  vascular  loops  given  off  by  the  under- 
lying vessels  (Fig.  17). 

Suppose  this  pus-secreting  layer  to  be  folded  up  by 
bringing  the  opposite  edges  and  surfaces  together,  and 
the  same  arrangement  is  obtained  as  in  healing  by  the 
first  intention. 

The  granulations  continue  to  grow  until  at  length 
they  reach  the  level   of  the  surrounding  surface,   or 


Fig.  17. — Diagram  of  Granulation  of  a  Wound. 

The  laj'er  of  pus  cells  is  represented  as  having  heen  acted  on  hy  acetic  acid,  to 
distmsTLiish  the  pus  cells  in  the  figure  more  accurately  from  the  grauulatlon 
cells  (.Billroth). 


pass  beyond  it.  As  the  inflammation  subsides  the 
secretion  of  pus  diminishes,  and  organisation  of  the 
granulation  tissue  takes  place.  Henceforth  the  case 
is  one  of  a  healing  ulcer  {q.v.).  The  pus  is  derived 
from  two  sources  :  direct  exudation  from  the  vessels, 
and  liquefaction  of  the  uppermost  stratum  of  the 
granulations.  The  drying  up  of  the  secretion  is  not 
simply  the  result  of  removal  of  the  cause  of  irritation. 


172  '  Surgical  Pathology.        [Chap. xxiii. 

There  is  an  inlierent  tendency  to  a  typical  end  by 
organisation  of  the  neoplasia,  the  same  as  obtains  in 
normal  development  from  embryonic  tissue. 

In  lacerated  wounds  portions  of  tissue  are 
killed  outright,  for  the  vessels  are  twisted  and  bruised, 
besides  being  ruptured.  Before  union  can  take  place, 
the  dead  parts  must  be  thrown  off;  this  is  effected 
partly  by  the  vital  absorbent  action  of  the  granulation 
cells,  partly  by  molecular  disintegi'ation  of  the  sloughs 
(post-mortem  decomposition). 

Lacerated  wounds  inflame  more  than  incised  ones, 
for  the  injury  to  the  tissues  is  greater,  and  the 
irritation  is  increased  by  the  chemical  products  of  the 
breaking  up  of  necrosed  shreds ;  hence  suppuration  is 
more  profuse  and  prolonged,  and  wider  tracts  are  left 
to  cicatrise.  Although  the  cicatrisation  is  a  conserva- 
tive process,  it  may  entail  serious  consequences  from 
displacement  of  certain  parts  by  traction.  Ectropion, 
or  eversion  of  the  eyelid,  is  an  instance  of  this. 

Besides  the  extent  of  the  injury,  the  nature  of  the 
tissue  wounded  has  much  to  do  with  the  rate  of 
healing  ;  as,  for  instance,  in  tendon,  where  the  vessels 
are  few,  the  anastomoses  scanty,  and  the  density  of 
structure  prevents  a  ready  opening  up  of  collateral 
channels.      In  the  last  respect  it  resembles  bone. 

Union  of  opposed  granulating  surfaces. — 
This  is  much  rarer  than  healing  by  the  first  intention 
or  by  open  granulation.  A  sinus  or  blind  fistula  has 
only  one  opening  on  the  surface.  Its  walls  may  be 
formed  of  healthy  granulations,  and  yet  union  may  be 
indefinitely  delayed  from  the  tension  of  pent-up  dis- 
charge, progressive  disease  at  the  botton  of  the  sinus, 
or  the  friction  of  the  opposed  surfaces;  the  last  keeping 
up  irritation  and  preventing  the  granulations  from 
lying  in  contact  in  a  state  of  rest.  Instances  of  this 
ai'e  met  with  in  sinuses  beneath  the  scalp  and  pectoral 
muscles,  and  in  the  groin.      Fixation  of  the  muscles 


Chap.  XXIII.]  Union  OF   Wounds.  173 

and  external  pressure  are  often  sufficient  to  cause  them 
to  close. 

Tlie  discliarge  from  the  granulations  having  been 
greatly  diminished,  the  opposed  surfaces  are  no  longer 
kept  apart.  What  little  fluid  lies  between  them  is 
taken  up  by  the  vessels.  Fibrinous  exudation  glues 
the  granulations  together,  and  henceforth  the  mode  of 
union  is  that  of  healing  by  the  first  intention,  except 
at  the  orifice,  which  is  reduced  to  a  small  surface  ulcer 
that  cicatrises  in  the  usual  way. 

Healiog:  by  scabbing*. — The  epidermis  is  grazed 
off,  and  the  tips  of  the  papillae  are  bruised  and  slightly 
lacerated.  There  is  very  little  bleeding.  The  coagulum 
which  forms  on  the  surface  is  increased  by  subsequent 
fibrinous  exudation.  As  the  inflammation  subsides 
the  scab  dries  up  and  breaks  away  at  the  margin;  but 
before  it  is  detached  a  new  layer  of  epithelium  covers 
the  exposed  papillae.  The  wound  is  well  before  there 
is  time  for  development  of  new  vessels  in  the  scanty 
effusion. 

We  have  yet  to  explain  the  mode  of  healing  in 
wounds  of  certain  tissues — tendon,  muscle,  nerve, 
cartilage,  and  bone. 

TTouuds  of  tendons. — The  simplest  case  is 
subcutaneous  division  of  a  tendon,  say  that  of  the  heel. 
The  muscular  end  is  drawn  away  so  that  a  gap  is 
formed;  this  is  immediately  filled  up  by  sinking  in  of 
the  skin  and  effusion  of  blood. 

The  clot  is  quickly  absorbed,  and  its  place  taken  by 
plastic  lymph,  which  exudes  from  the  vessels  of  the 
tendon-sheath  and  adjacent  areolar  tissue.  The  tendon 
itself,  on  account  of  its  density  and  defective  vascular 
supply,  takes  but  a  minor  share  in  the  earlier  repara- 
tive changes.  The  lymph,  which  is  thickly  set  with 
leucocytes,  not  only  joins  the  tendon  end  to  end,  but 
overlaps  the  edges,  giving  rise  to  a  fusiform  swelling. 
Vascular  loops  from  the  vessels  of  the  surrounding 


174  Surgical  Pathology.        [Chap.  xxiii. 

tissue  lie  athwart  the  axis  of  the  tendon,  and,  passing 
inwards,  join  with  those  of  the  opposite  side,  and,  later 
on,  with  similar  loops  from  the  cut  surfaces  of  tendon. 
In  some  respects  this  is  a  repetition  of  the  growth  of 
provisional  and  definitive  callus  in  bone  fractures. 

The  vascular  cementing  medium  organises  to 
connective  tissue,  and  this  undergoes  cicatricial  con- 
traction. The  scar-like  tissue  reverts  pretty  closely 
to  the  normal  histological  type,  parallel  bundles  of 
fibres  with  interfascicular  connective-tissue  corpuscles. 

Lacerated  wounds  are  slow  to  heal,  for  they 
always  cause  death  of  a  considerable  portion  of  tissue, 
and  it  takes  some  time  to  throw  off  the  softened 
shreds  on  account  of  the  small  supply  of  vessels  in 
tendon.  The  superficial  ulceration  left  after  the 
deeper  part  is  healed  is  troublesome,  for  the  skin  is 
bound  down  at  the  margin,  and  the  contraction  of 
the  muscle  keeps  up  irritation ;  hence  the  need  of 
mechanical  appliances  to  restrain  movement. 

TVounds  and  injuries  of  muscle.— Voluntary 
muscle  is  highly  vascular,  and  its  anastomoses  are  free 
and  extensive. 

When  incised,  muscle  retracts  more  than  any  other 
tissue ;  the  gap  between  the  divided  ends  is  quite 
large.  Bleeding,  thrombosis  to  arrest  it,  and  subse- 
quent absorption  of  the  clot,  occur  as  in  wounds  of 
connective  tissue.  Granulation  tissue  is  plentifully 
produced.  The  cells  are  mostly  derived  from  the 
blood-vessels,  but  it  seems  probable  that  the  nuclei  of 
the  muscular  fibres  are  aroused  by  the  local  irritation 
to  renewed  formative  activity. 

On  division  or  rupture  of  the  muscular  fibres  the 
contractile  substance  coils  up  somewhat  within  the 
sarcolemma,  so  that  the  ends  become  more  or  less  club- 
shaped. 

The  ends  of  the  fibres  degenerate  and  split  up 
longitudinally,   and   the    nuclei    to    the    same  extent 


Chap.  XXIII.]  Union  of   Wounds. 


175 


become    granular    from    fatty    metamorphosis.       The 
degenerated  products  are  absorbed,  and  the  muscular 


Fig.  18. — Ends  of  Divided  Muscular  Fibres,  from  the  Biceps  Muscle 
of  a  Eabbit,  eight  days  after  the  inj  ury, 

a,  6,  c,  Old  muscular  fibres ;  a,  the  contractile  substance  rolled  up  and  balled 
together ;  the  same  way  in  the  bundle  above  d ;  into  the  pointed  cornet- 
shaped  sarcolemma  tube,  c,  there  extends  a  series  of  young  muscular  nuclei, 
between  which  there  is  very  delicate  transversely-striated  substance ;  e,  young 
free  muscle  cells  ;  /,  two  young  ribbon-like  muscular  filaments  ;  g,  the  same, 
of  various  sizes,  isolated,     x  450     (From  Billroth  ;  after  O.  Weber.) 

fibres  are  seen  to  be  lying  in  a  bed  of  proliferating 
granulation  tissue. 

In  the  lower  animals  fusiform  cells  derived  from 
the  old  muscle  nuclei  (Weber  and  Gussenbauer)  and 
wandering  corpuscles  (Maslowsky)  have  been  found  to 
enlarge  and  become  transversely  striated,  so  that  to 


176  SURGICA  L    Fa  THOLOGY.  Chap.  XXI 1 1 . 

some  extent  the  union  is  by  muscular  fibre.  Observa- 
tions are  wanting  to  show  if  this  occurs  in  the  human 
subject.  Connective  tissue  cicatrisation  is  certainly 
the  rule,  but  from  what  we  know  of  the  repair  of 
injured  nerves  there  seems  no  reason  why  muscular 
fibres  should  not  be  regenerated. 

If  the  divided  ends  of  a  muscle  be  approxi- 
mated, a  narrow  seam  of  fibrous  tissue  is  left.  If 
there  be  much  loss  of  substance,  or  the  ends  be  allowed 
to  separate,  union  is  effected  by  a  tendinous  band, 
and  the  muscle  remains  more  or  less  digastric. 

Wounds  and  injuries  of  nerves. — There  are 
two  remarkable  facts  connected  with  wounds  and 
injuries  of  nerves.  (1)  The  range  of  influence  of 
nerve  tissue  over  the  mode  of  repair  is  very  limited  ; 
the  divided  ends  must  be  in  close  proximity  to  insure 
union  by  other  than  connective  tissue.  (2)  Extensive 
destruction  of  nerve  cells  and  fibres  is  compatible  with 
continued  function  of  the  parts  supplied  by  them.  A 
patient  may  be  but  little  incapacitated  by  partial 
absorption  and  annular  sclerosis  of  the  spinal  cord  from 
caries  of  the  vertebrae  (Charcot)  ;  and  haemorrhages, 
softening,  and  cysts  of  i3he  optic  thalami  and  corpora 
striata  may  leave  very  little  impairment  of  function. 
In  these  cases  it  seems  more  probable  that  the 
remaining  elements  take  on  increased  action,  than 
that  new  ones  are  formed. 

As  in  muscle,  the  power  of  repair  is  greater  in  the 
lower  animals  than  in  man. 

Brown- Sequard  found  that  the  paralysis  caused  by 
division  of  the  spinal  cord  in  pigeons  disappeared  after 
a  time. 

The  approximated  ends  of  a  divided  nerve  will 
unite  quite  well  if  disturbing  influences  be  excluded. 
This  is  seen  after  certain  accidents  and  operations  ; 
e.^.,  the  sensibility  of  the  skin  of  the  lower  lip  and 
chin  may  be  restored  after  laceration  of  the  mental 


Chap.  XXIII, ] 


Union  of  Wounds. 


177 


nerve  from  fracture  of  the  jaw,  and  the  conductivity 
of  the  superficial  cervical  is  re-established  in  the  case 
of  ligature  of  the  carotid  artery.  Again,  portions  of 
transplanted  skin  become  sensitive  as  nerve-fibres  pass 
through  the  cicatrix  to 
pick  up  or  replace  those  in 
the  graft. 

Upon  division  of  a 
nerve,  degenerative  changes 
ensue  to  a  limited  extent, 
less  in  the  proximal  than 
in  the  distal  end,  for  it 
maintains  its  connection 
with  the  central  ganglion 
cells. 

The  white  substance  of 
Schwann  breaks  up,  and 
the  primitive  sheath  is  ap- 
plied to  the  axis-cylinder, 
the  most  durable  part  of 
a  nerve-fibre. 

Leucocytes  infiltrate 
the  part,  and  possibly  the 
nerve  nuclei  increase  in 
number.  Some  of  the  in- 
difierent  cells  become  fusi- 
form, and,  growing  into  nerve-fibres  with  double  con- 
tour, pick  up  the  ends  of  the  old  axis-cylinders,  and  the 
nerve  cicatrix  is  fully  formed  (Fig.  19).  Short  of  this, 
the  newly-formed  fibres  remain  embedded  in  the  con- 
nective tissue  scar,  and  the  distal  end  of  the  divided 
nerve  undergoes  progressive  atrophy,  a  reason  for 
early  operation  in  cases  where  nature  has  failed  to 
effect  the  required  union. 

According  to  some  authors,  the  proximal  part  of 
the  axis-cylinder  elongates  and  joins  directly  with  the 
distal. 

M 


Fig.  19. — Eegeneration  of  Nerve. 
From  the  Frog  ten  weeks  after 
division.  Development  of  young 
Nerve-cells  from  Spindle-cells. 
X  300.  {After  Hjelt.  'Erom  Bill- 
roth's  "  Surgical  Pathology.") 


J  78  Surgical  Pathology.        [Chap.  xxiv. 

'^''©Iliads  or  fractures  of  cartilage  unite  by 
connective  tissue,  and  in  the  case  of  the  costal 
cartilages,  occasionally  by  bone.  There  is  little,  if  any, 
reproduction  of  cartilage  cells.  (In  ununited  fractures 
of  bone  the  ends  of  the  fragments  are  sometimes 
capped  with  hyaline  cartilage ;  this  is  in  accord- 
ance with  the  fact  that  the  enchondromata  spring 
from  bone  or  periosteum.)  If  a  piece  be  split  off  an 
articular  cartilage,  the  remaining  portion  proliferates 
at  the  seat  of  injury,  the  corpuscles  divide  and  sub- 
divide, and  the  capsules  and  matrix  soften.  The 
granulation  layer  thus  formed  organises  to  fibrous 
tissue.  The  loss  of  substance  is  never  completely 
repaired,  but  a  depressed  cicatrix  remains.  When 
the  injury  implicates  the  synovial  membrane  vascular 
loops  grow  into  the  granulation  tissue,  but  they 
disappear  as  cicatrisation  advances. 


CHAPTER   XXIY. 

FRACTURES    OF    BONE    AND    PSEUDARTHROSIS. 

Simple  fractiu-e. — When  the  shaft  of  a  long 
bone  is  broken,  there  is  bleeding  from  the  vessels  in  the 
central  medulla,  Haversian  canals,  and  periosteum, 
and  also  from  the  soft  tissues  round  about,  if  these 
be  lacerated  by  the  displacement  of  the  fragments. 
If  the  bleeding  has  been  excessive,  fluctuation,  or 
bogginess,  may  be  felt  over  the  seat  of  fracture,  and 
there  is  ecchymosis  of  the  skin,  and  perhaps  also 
bullse  fi.lled  with  blood-stained  serum.  The  staining 
of  the  skin  becomes  more  marked  after  a  while,  for 
the  blood  corpuscles  break  up,  and  the  colouring 
matter  is  diffused  through  the  tissues. 


Chap.  XXIV.]  Fracture  of  Bone.  179 

When  the  bone  is  deeply  placed,  or  the  break  in 
it  is  a  mere  fissure,  there  may  be  no  discoloration  of 
the  skin,  or,  at  the  most,  only  a  light-yellow  tinting 
from  haemoglobin  that  has  passed  through  the  usual 
changes  before  it  has  reached  the  surface.  Such  may 
be  seen  in  Scarpa's  triangle  a  few  days  after  intra- 
capsular fracture  of  the  neck  of  the  femur. 

Possibly  a  portion  of  the  coagulum  around  the 
ends  of  the  fragments  organises,  but  certainly  the 
greater  part  is  re-absorbed. 

Inflammatory  changes. — The  swelling  of  the  part 
is  increased  by  exudation,  which  often  causes  oedema 
of  the  soft  structures.  There  may  be  redness  of 
the  skin  from  hypersemia.  The  inflammatory  changes 
set  in  immediately  after  the  injury,  and  the  products 
at  first  mingle  with  the  extravasated  blood,  which, 
together  with  the  serous  portion  of  the  exudation,  is 
removed  by  absorption.  Then  it  is  that  the  more 
plastic  fibrinous  material  can  be  felt  as  a  firm  sub- 
stance imbedding  the  broken  ends  of  the  bones.  This 
will  be  about  the  end  of  the  first  week,  when  it  is 
said  the  callus  begins  to  form. 

It  must  not  be  supposed  that  up  to  the  present 
there  has  been  a  simple  sequence  of  three  events  : — • 
haemorrhage  and  absorption  of  blood,  serous  eflfusion 
and  absorption,  and  the  beginning  of  callus-formation. 
These  processes  overlap  one  another,  as  it  were,  and 
it  is  only  the  maximum  development  of  each  that  is 
noted  as  a  distinct  phase. 

The  result  of  the  inflammation  is  that  the 
medulla  (subperiosteal,  central,  and  interstitial  or 
Haversian)  has  been  converted  into  embryonic  tissue, 
the  cells  of  which  lie  fixed  in  a  bed  of  firm  inter- 
cellular substance. 

The  early  induration,  which  is  more  marked  than 
in  any  other  situation,  takes  place  under  the  physio- 
logical law  that  rules  the  natural  growth  of  bone. 


i8o  Surgical  Pathology.        TChap.  xxiv. 

The  cells  of  the  callus  are  derived  from  the 
blood-vessels,  the  bone  corpuscles  probably  taking  no 
active  part  in  the  process. 

So  far  as  the  bone  is  concerned,  the  embryonic  or 
granulation  tissue  is  limited  externally  by  the  peri- 
osteum. It  forms  a  thin  layer  between  the  ends  of 
the  fragments,  and  fills  up  for  a  short  distance  the 
open  ends  of  the  Haversian  canals.  It  also  blocks  the 
medullary  canal.  The  fat  cells  of  the  central  medulla 
are  broken  up  and  their  contents  absorbed. 

The  inflammatory  new  formation  is  in  greatest 
amount  opposite  the  fracture,  i.e.,  where  the  irritation 
from  the  injury  is  most  intense ;  from  this  point  it 
subsides  gradually,  so  that,  if  the  broken  ends  be  in 
accurate  coaptation,  they  will  be  ensheathed  by  a 
regular  fusiform  collar  or  ferrule. 

Cartilaginous  tramsformation  of  the  cal- 
lus.— Some  bones  are  developed  directly  from  embry- 
onic tissue,  and  all  grow  in  thickness  from  the  same ; 
but  many,  e.g.,  the  long  bones,  ossify  from  a  carti- 
laginous basis  until  their  full  length  is  attained.  So, 
in  fractures,  the  callus  formed  of  indurated  granula- 
tion tissue  may  ossify  forthwith,  or  pass  through  the 
intermediate  state  of  cartilage.  The  reason  why  one 
fracture  should  unite  through  the  medium  of  carti- 
lage, and  another  without  it,  is  no  clearer  than  that 
of  the  corresponding  variation  in  normal  development 
and  growth. 

According  to  Cornil  and  Ranvier,  the  callus  of 
simple  fractures  is  converted  into  cartilage ;  that  of 
compound  fractures  is  not. 

Billroth,  ignoring  this  absolute  distinction,  says  : — 
"  In  rabbits,  the  callus  is  always  changed  to  cartilage 
before  ossification,  as  it  also  is  in  children.  In  old 
dogs  the  callus  usually  ossifies  directly,  as  in  the 
human  adult."  The  irritation  in  a  compound  frac- 
ture, where  there  is  more  or  less  suppuration,  may  be 


Chap.  XXIV.] 


Fracture  of  Bone. 


i8i 


too  great  to  allow  of  the  necessary  conditions  (o£ 
which  one  is  rest)  for  the  transformation  of  exuda- 
tion into  cartilage  cells,  and 
plasma  into  cartilage  matrix. 

Age  is  likely  to  influence 
the  event ;  for  in  adults  the 
natural  formative  activity  of 
cartilage  is  almost  m/,  and 
cartilage  tumours  do  not 
often  show  themselves  late  in 
life.  On  the  other  hand,  car- 
tilage is  always  present  in  the 
growth  of  osteophytes  about 
the  joints  in  chronic  rheumatic 
arthritis. 

Cartilage  first  appears  at 
the  upper  and  lower  borders 
of  the  callus,  both  in  the  peri- 
osteal and  central  portions.  It 
continues  to  grow  until  the 
chondrification  is  complete. 

Vascularization  of  the 
callus. — The  blood-vessels  of 
the  bone  and  periosteum  give 
off  loops  into  the  young  peri- 
pheral  callus;  those  of  the  bone  ^IracwTildfurAbtt 
only  into  the  central  callus. 

The  new  vessels  lie  at  right 


after     the 


angles  to  the  axis  of  the  bone 


three  weeks 
injiory. 
a.  Compact  bone  of  shaft;  6, 
callus ;  c,  cartilage  formed  In 
the  callus;  d,  cartilaginous 
epiphyses  ;  the  callus  is  chiefly 
deposited  in  the  concavity  lif 
the  fracture-curve.  (Natural 
size.)  From  a  preparation  by 
Dr.  Silc  .ck. 


in  each  case. 

Yascularisation  of  the 
callus  between  the  opposed 
fragments  is  much  slower  than  on  the  surfaces  ;  for 
the  old  vessels  are  pent  up  in  the  Haversian  canals 
(except  at  the  torn  ends,  which  are  plugged  with 
clots),  the  rigid  walls  of  which  retard  dilatation  and 
lateral  looping ;  and  hence  it  is  some  time  before  the 


i82  Surgical  Pathology.        [Chap.  xxiv. 

continuity  of  the  vessels  in  the  two  fragments  is  re- 
established. 

Ossification  of  tlie  callus. — "Whether  carti- 
lage be  formed  or  not,  lime  salts  are  deposited  around 
the  blood-vessels  imbedding  the  immediate  granulation 
cells  (osteoplasts).  This  follows  in  close  order  upon 
the  growth  of  the  vessels,  and,  in  the  superficial 
callus,  advances  from  the  bone  and  periosteum  at  the 
same  time.  The  primary  trabecul{«  of  bone  form 
moulds  around  the  vessels. 

As  ossification  advances,  the  osteal  and  periosteal 
spiculfe  meet  and  widen,  but  the  ossified  callus  never 
attains  the  density  of  compact  bone  ;  for,  before  that 
stage  is  reached,  retrogressive  or  absorptive  changes 
set  in. 

The  osseous  columns  in  the  central  and  external 
callus  lie,  like  the  vessels,  parallel  to  the  transverse 
axis  of  the  shaft  of  the  bone. 

By  the  end  of  the  first  week,  or  a  little  later, 
ossification  has  commenced ;  by  the  end  of  the  third 
it  is  sufficiently  extensive  to  enable  the  callus  to 
support  the  bone  without  fear  of  bending  or  re- 
fracture. 

If  the  callus  be  changed  to  cartilage,  ossification 
goes  on  after  the  physiological  type.  The  primary 
capsules  contain  secondary  capsules,  which,  dissolving, 
set  free  broods  of  embryonic  cells  derived  from  proli- 
feration of  the  cartilage  cells.  By  absorption  of  the 
capsules  and  matrix,  festooned  passages  filled  with 
indifferent  cells  are  opened  up.  Into  these  blood- 
vessels grow,  whilst  lime  salts  are  deposited  in  the 
matrix.  So  far  there  is  only  calcification.  True 
ossification  is  established  by  the  inclosure  of  osteo- 
plasts as  bone  corpuscles  in  the  ossifying  matrix, 
corpuscles  which  unite  by  their  processes,  and  lie  in 
lacunar  spaces  that  join  one  another  and  the  central 
canals  of  the  new  Haversian  systems. 


Chap.  XXIV.]  Fracture  of  Bone.  183 

Provisional    and    definitive    callus. — Du- 

puytren  gave  the  name  'provisional  to  the  callus 
formed  about  the  ends  of  the  fragments  (that  which 
causes  the  fusiform  swelling  on  the  surface,  and  blocks 
the  medullary  canal)  since  it  provided  for  the  union 
and  support  of  the  fracture  pending  the  construction 
of  the  final  or  definitive  callus  between  the  broken 
surfaces. 

The  amount  of  provisional  callus  depends  chiefly 
upon  the  extent  of  the  injury  to  the  bone  and  soft 
parts.  In  comminuted  simple  fractures  it  is  quite 
large,  and  welds  the  fragments  into  a  continuous 
mass.  In  children  it  is  more  largely  developed  than  in 
adults. 

If  there  be  no  displacement  of  the  fragTnents, 
which  require  but  little  support,  as  in  fissured  fracture 
of  the  skull,  it  may  be  so  small  as  to  escape  detection. 
The  provisional  callus  so  far  disappears  that  the 
central  canal  is  re-established  and  all  external  signs  of 
the  fracture  lost,  providing  there  has  been  little  or  no 
displacement  of  the  fragments.  Its  complete  absorp- 
tion requires  months. 

Definitive  callus^  though  slow  in  forming,  far 
exceeds  the  provisional  in  density ;  indeed,  it  becomes 
more  compact  than  the  old  bone,  hence  the  saying, 
"  A  bone  does  not  break  twice  in  the  same  place." 

As  the  result  of  the  injury  a  rarefying  ostitis 
(5'. v.)  is  set  up  in  the  ends  of  the  fragments.  This 
goes  on  until  the  bone  is  quite  porous,  and  the  canals, 
enlarged  by  absorption,  are  filled  with  vascular  fungous 
granulation  tissue.  The  blood-vessels  from  the  op- 
posite fragments  m^eet  and  unite.  Lime  salts  are 
deposited  around  them,  so  that  the  new  bony  tra- 
becules, unlike  those  of  provisional  callus,  lie  in  the 
long  axis  of  the  bone  ;  and  the  continuity  of  the 
Haversian  canals  is  once  more  established. 

The  rarefjdng  or  destructive  ostitis  subsides  into 


184  Surgical  Pathology.        [Chap.  xxiv. 

a  sclerosing  or  constructive  ostitis,  and  when  this 
ceases  repair  is  complete.  The  provisional  callus  is 
absorbed  fari  passu  with  the  formation  of  the  de- 
finitive. 

The  amount  of  provisional  callus  formed,  and  the 
extent  of  the  rarefying  ostitis,  vary  as  the  intensity  of 
the  inflammation,  and  this  as  the  degree  of  injury. 

Cliaug^es  in  the  periosteiim,  etc, — The  me- 
dullary layer  is  converted  into  granulation  tissu.e,  and 
thence  to  callus. 

The  fibrous  layer  becomes  indefinite  in  outline, 
and  commonly  lost  in  the  softened  mass.  In  the 
latter  event,  a  new  periosteum  is  formed  from  the 
superficial  cells  of  the  callus. 

The  development  of  new  bony  callus  is  not  con- 
fined to  the  periosteum  and  bone ;  the  tendons  and 
connective  tissue  of  the  muscles  are  likewise  osteo- 
plastic. In  simple  fracture  without  displacement 
they  do  not  enter  into  the  process  of  repair,  but  where 
there  is  much  laceration  of  the  soft  structures  they 
are  very  active.  The  muscular  fibres  undergo  absorp- 
tion corresponding  in  extent  to  the  osteoplastic  change 
in  the  interstitial  tissue. 

When  a  fracture  passes  through  a  strong  ten- 
dinous insertion,  the  callus  at  that  part  is  increased 
by  the  physiological  tension  upon  the  tendon ;  and 
when  ossified,  it  may  remain  as  a  permanent  osteo- 
phyte, whilst  in  the  other  parts  it  is  completely 
absorbed. 

Fracture  tlirougli  epiphyisial  cartilage  is 
in  reality  fracture  at  the  line  of  junction  of  the 
cartilage  with  the  bone,  so  that  one  fragment  carries 
the  whole  or  greater  part  of  the  cartilage  with  it. 
This  is  the  reason  why  epiphysial  fractures,  so  common 
in  children,  do  not,  as  a  rule^  lead  to  a  stunted  growth 
of  the  bone.  Severe  injury  may  cause  the  cartilage 
to  be  entirely  converted  into  embryonic  tissue,   and 


Chap.  XXIV.]         Fracture  of  Bone. 


this  again  into  ossified  callus, 
so  that  at  one  end  the  bone  is 
arrested  in  its  growth  length- 
wise, but,  as  a  rule,  a  part  of 
the  cartilage  escapes  the  inflam- 
matory change. 

The  cartilage  developed  in 
the  callus  probably  ossifies 
throughout.  It  does  not  appear 
to  possess  the  physiological  pro- 
perty of  continuous  segmentation 
and  reproduction  (Fig.  21). 

In  fracture  through  the  epi- 
physis of  the  lower  end  of  the 
humerus,  the  provisional  callus 
partly  fills  the  coronoid  and 
olecranon  fossae,  and  for  a  time 
checks  the  movements  at  the 
joint.  The  crepitus  is  not  so 
hard  and  grating  as  in  fracture 
through  bone. 

Failure  of  ossific  union. 
— The  causes  of  non-union  are 
constitutional  and  local.  The  con- 
stitutional causes  are  those  that 
impair  the  healthy  nutritive  and 
formative  activity  of  the  tissues  in 
general,  and  in  one  disease  (molli- 
ties  ossium)  bone  tissue  in  par- 
ticular. Chronic  Bright's  disease, 
tertiary  syphilis,  and  cancerous 
cachexia  may  be  cited  as  systemic 
defects  likely  to  prevent  bony  Fig.21.— Defec- 
union,  and  permanently  so.  Frac-  o/EaSusS^ 
t  ures  are  slow  to  unite  during:  acute 
specific  fevers,  and  afterwards  if 
convalescence  be  protracted. 


result  of  frac- 
ture of  tlie 
Lower  Epiphysis. 

A  ridge  of  bone  is  seen  at  the 
seat  of  union.  (Reduced  one- 
half.) 


1 86  Surgical  Pathology.        [Chap.  xxiv. 

The  local  causes  are  :  (1)  Tliose  tliat  prevent 
coaptation  of  the  fragments  ;  (2)  movement  of  the 
fragments  one  upon  the  other  ;  (3)  defective  vascular 
supply. 

Separation  of  tlie  frag-ineiits  may  be  effected 
by  (a)  muscular  action,  as  in  fracture  of  the  patella 
and  olecranon ;  (6)  the  hydrostatic  pressure  of  the 
effusion  into  the  neighbouring  joint,  e.g.,  the  knee  ; 
(c)  the  interposition  of  a  foreign  body,  such  as  muscle 
tendon,  a  detached  portion  of  bone,  a  tooth  in  fracture 
of  the  jaw,  or  the  necrosed  end  of  one  of  the  frag- 
ments. 

Wide  separation  by  muscular  action  means  that 
the  new  formation  connecting  the  fragments  is,  at  the 
part  most  distant  from  the  bone,  removed  from  the 
sphere  of  influence  of  the  physiological  stimulus  to 
ossification  possessed  by  the  bone  and  periosteum. 

Movemeiit  of  tlie  fragments  entails  more 
than  the  absence  of  coaptation.  In  a  case  of  trans- 
verse fracture  of  the  patella  where  the  patient  died 
from  cellulitis  of  the  limb  set  up  by  the  use  of  Mal- 
gaigne's  hooks,  I  found  the  fractured  surfaces  thickly 
studded  with  needle-like  processes  of  new  bone,  a 
sixth  of  an  inch  in  length.  Now  movement  would 
tend  to  break  off  the  tips  of  these  minute  stalactites, 
but  would  not  prevent  their  fusion  into  a  continuous 
layer  by  lateral  growth. 

It  seems  strange  at  first  sight  that  movement 
should  cause  an  exuberance  of  callus,  and  yet  in  some 
cases  prevent  osseous  union.  The  explanation  is  pro- 
bably in  the  degree  and  continuance  of  movement. 
If  the  callus  sufiices  to  lock  the  fragments  together, 
it  will  ossify  ;  if  it  fails  to  do  this,  it  will  not. 

Defective  vascnlar  smpply. — I  believe  this 
has  little  to  do  with  the  failure  of  union  in  the  case 
of  the  patella  and  olecranon.  In  fracture  through 
the  anatomical  neck  of  the  humerus,  the  blood  supply 


Chap.  XXIV.] 


FSE  UDA  R  THR  OSIS. 


187 


can  only  come  from  one  surface ;  and  in  intracapsular 
fracture  of  the  neck  of  the  femur,  the  cervical  liga- 
ment (periosteum)  is  usually  torn,  and  the  head  of 
the  bone  gets  very  little  nutriment  through  the  liga- 
mentum  teres,  even  if  the  latter  is  not  ruptured  by 
the  accident. 

Pseudartlii'oses,  or  false  joints. — Causes.— 
(1)  Ununited  fracture;  (2)  unreduced  dislocation. 

There  are  two  varieties  of  false  joint  as  the  result 
of  ununited  fracture :  ia)  ligamentous,  (6)  diarthrodial. 

L.ig'ameiitous  pseiidartlirosis  is  seen  in  frac- 
tures of  the  patella,  olecranon,  acromion,  and  neck  of 
the  femur  within  the  capsule. 

Unless  the  fragments  be  separated  by  serous 
effusion  into  the  neighbouring  joint,  e.g.,  in  the  knee, 
in  many  cases  of  fracture  of  the  patella,  the  interval 
between  them  is  soon  filled  up  with  soft  granulation 


Fi^".  22. — Ununited  Fracture  of  Olecranon. 

a.  Upper  fragnu'iu;   h,  litramentoiis  band  joining  the  two  fragments; 
c,  humerus ;  d,  orbicular  ligament ;  e,  triceps  tendon. 


tissue,  the  vessels  of  which  are  derived  from  the 
broken  surfaces  and  the  surroundino-  tissues.  As  the 
granulation  tissue  oro^anises  the  fibrous  bundles  lie 
})arallel   to    the   line    of   greatest   tension,    i.e.,    from 


fragment  to  fragment. 


Surgical  Pathology.      [Chap.  xxiv. 


The  clistensit)ility  of  tlie  young  connective  tissue 
accounts  for  the  separation  of  the  fragments  subse- 
quent to  their  having  been  in  pretty  close  apposition. 
Cartilage    cells    may  sometimes  be  found   in  the 
meshes  of  the  fibrous  tissue  at  the  fractured  surfaces. 

l>iarttirodial  pseudartlirosis.  —  The   move- 
ment of  one  fragment  upon  the  other  may  be  so  free 

as  to  prevent  the  growth  of 
granulation  tissue  between  the 
surfaces,  or,  if  it  have  formed, 
to  cause  its  re  -  absorption. 
This  variety  of  false  joint  is 
found  in  the  long  bones.  The 
medullary  cavity  on  each  side 
of  the  fracture  is  filled  with 
callus,  which  may  or  may  not 
I  change  to  cartilage.  The  callus 
ossifies,  but  instead  of  being  re- 
absorbed, as  is  the  case  when 
bony  union  occurs,  it  remains 
as  a  permanent  compact  mass. 
S  This  result  is  due  to  the  fric- 
tion kept  up  between  the  frag- 
ments, whereby  a  condensing 
ostitis  is  maintained.  Mean- 
while the  granulation  tissue 
formed  from  the  soft  tissues 
around  the  fracture  organises, 
and  the  broken  ends  are  en- 
Fig.  23  —Ununited  Fiao-  closcd  within  a  dense  fibrous  cap- 
tSo£l?r™Toint''""  sule.  When  the  cartilaginous 
a.  Medullary  cavity  of  the   callus  witMu  the  medullary  caual 

bone;  6,  compact  bone  clos-  •  n  •  i  i  u 

ing    the    medullary    cavity     OSSltieS,     an      HTCgular     Jaycr     01 

next  "  the  joint ;"  c,  layer  nf    in-  im  •  ,' 

cartilage ;  d,  fibrous  capsule   nyaime    Cartilage  IS    sometimes 

containing  a  nodule  of  bone.    ^    oi  xi,  £  /XT'*         oo\ 

left  upon  the  surrace  (.rig.  23). 
A  natural  joint  is  further  simulated  by  the  change  in 
shape  of  the  fragments  as  they  rub  together,  the  cup- 


Chap.  XXIV.]  PSEUDARTHROSIS.  1 89 

shaped  hollow  of  one  receiving  the  rounded,  extremity 
of  the  other.  The  cavity  of  the  false  joint  contains  a 
little  serum  (not  synovia)  exuded  from  the  vessels  of 
the  capsule. 

Pseiidarthrosis  from  imrecluced  disloca- 
tion.— This  may  happen  from  disease  or  injury.  In 
the  former  case  the  cartilage  of  the  old  joint  is 
removed  before  the  dislocation  occurs.  In  caries  of 
the  hip  pint  the  head  of  the  femur  is  more  or  less 
absorbed,  as  is  also  the  rim  of  the  acetabulum,  on  the 
side  of  the  dislocation  where  there  is  softening  from 
caries,  and  atrophy  from  the  continued  pressure  of  the 
head  of  the  femur ;  hence  the  luxation  usually  takes 
place  gradually.  The  capsule  of  the  hip  joint,  softened 
by  inflammation,  is  readily  stretched  by  the  localised 
tension  upon  it ;  and  at  last  it  gives  way,  or  is  entirely 
destroyed  by  the  disease  at  this  part. 

Subsequent  to  the  dislocation  the  caries  may 
subside,  and  the  granulation  tissue  become  fibrous, 
and  form  a  new  capsule  around  the  displaced  bone. 
Then  the  cotyloid  cavity  becomes  shallow,  from 
atrophy  of  its  margin  and  filling  in  of  the  hollow 
with  connective  tissue.  The  hip-bone  is  rough  from 
osteophytes  for  some  distance  beyond  the  primary  seat 
of  disease.  Where  there  is  greatest  movement  (inter- 
niittent  jjressitre)  of  the  femur  upon  the  hip,  the  irri- 
tation causes  a  buttress  of  bone  to  be  thrown  out, 
which  serves  as  a  support  to  the  dislocated  femur. 
This  constructive  process  may  go  on  even  whilst  the 
caries  of  the  bones  round  about  is  progressing 
(Fig.  36).  In  Charcofs  disease  two  factors  may  be 
concerned  in  the  dislocation  :  (1)  Erosion  of  the  bones  ; 
(2)  stretching  of  the  capsule  from  serous  efi'usion  into 
the  joint. 

Pseudartlirosis  from  traumatic  disloca- 
tion.— Here  the  dislocated  bones  are  healthy  at  the 
time  of  the  accident.     The  subsequent  changes  are  : 


190  Surgical  Pathology.        [Chap.  xxiv. 

(1)  Construction  of  a  fibrous  capsule  about  the  false 
joint ;  (2)  alteration  in  the  shape  of  the  bones  from 
mutual  pressure ;  (3)  partial  or  complete  absorption  of 
the  articular  cartilages;  (4)  diminution  in  depth  of 
the  old  articular  depressions  (glenoid,  cotyloid,  etc.); 
(5)  formation  of  a  buttress  of  support  for  the  dis- 
located bone. 

Union  of  Compound  Fractures. 

A  compound  fracture  may  be  converted  into  a 
simple  one  by  immediate  closure  of  the  wound  in  the 
skin  or  mucous  membrane. 

The  laceration  of  the  soft  structures,  which  is  con- 
siderable, gives  rise  to  a  good  deal  of  extravasation, 
and  may  possibly  cause  suppuration  about  the  fracture 
after  the  external  opening  has  closed. 

Besides  the  extent  of  the  injury  to  the  soft  tissues, 
splinters  of  bone  may  be  detached,  and  the  ends  of 
the  fragments  may  necrose  from  stripping  off  of  the 
periosteum,  or  consecutive  inflammation.  Taking  an 
uncomplicated  case  of  compound  fracture,  with  suppu- 
ration, the  bone,  periosteum,  and  soft  tissues  implicated 
are  acutely  inflamed.  The  purulent  exudation  is  at 
first  mixed  with  disintegrating  blood-clot.  It  bathes 
the  broken  ends  of  the  bones,  which  are  quite  bare  at 
the  bottom  of  the  wound.  As  the  inflammation  sub- 
sides a  layer  of  vascular  granulation  tissue  lines  the 
whole  interior  of  the  wound.  This  for  a  time  con- 
tinues to  secrete  pus,  but  at  length  the  granulations 
from  opposite  sides  come  in  contact  and  their  vessels 
join. 

The  inflammatory  new  formation  passes  through 
the  usual  changes.  The  cells  that  remain  are  imbedded 
in  firm  intercellular  substance,  in  fact,  the  whole  is 
converted  into  a  mass  of  callus.  The  callus  organises 
into  bone  without  the  intermediate  formation  of 
cartilage    (Cornil    and   Eanvier).     It    rarely   ends   in 


Chap.  XXIV.] 


PSE  UDA  R  THR  OSIS. 


191 


fibrous  union  of  the  fracture.  The  bone,  periosteum, 
and  fibrous  structures  in  the  vicinity  are  all  active  in 
the  osteoplastic  process,  so  that  the  amount  of  pro- 
visional callus  is 
very  great. 

The  rarefying 
ostitis  of  the  ends 
of  the  fragments 
is  more  extensive 
than  in  simple  frac- 
ture, and  this  delays 
the  time  of  comple- 
tion of  the  definitive 
callus. 

Compound 
fracture,  with 
n  e  c  r  o  s  i  s. — Por- 
tions of  bone  may 
be  cut  ofi*  at  once 
from  all  vascular 
supply,  and  lie  loose 
at  the  seat  of  frac- 
ture;  or  necrosis  Fi?.  24.- Diagram  of  Fracture  of  a  Loii? 
of  the    ends    of    the  Bone,  with  external  Wound;  longitudinal 

section.    (Natural  size. ) 

fragments  may  en- 
sue from  the  vio- 
lence of  the  injury, 
stripping  ofi"  the  pe- 
riosteum and  caus- 
ing extravasation  into  the  Haversian  canals,  or  from 
arrest  of  the  circulation,  consequent  on  acute  inflam- 
mation. 

Loose  splinters  of  bone  may  retain  their  connection 
"with  the  periosteum,  and,  surviving  the  effects  of  the 
injury,  help  in  the  process  of  repair.  Necrosed  por- 
tions of  bone,  unless  removed,  keep  up  irritation,  and 
whilst  they  stimulate  to  increased  bone  formation  they 


e,  e,  bone  ;  /,  /,  /,  /,  soft  parts  of  the  limh  ;  a,  a,  ne- 
crosed ends  of  the  hone  ;  the  darkly-shaded 
part  represents  the  granulations  which  line  d, 
the  wound  that  opens  outwardly,  and  secrete 
pus  ;  b,  b,  internal  callus  in  the  two  dislocated 
ends  of  the  bone  ;  c,  c,  external  callus.  (,After 
Billroth.) 


192 


Surgical  Pathology. 


[Chap.  XXIV. 


prevent  closure  of  the  sinuses.  If  the  ends  of  the 
fragments  lose  their  vitality,  union  of  the  fracture  is 
greatly  delayed,  but  it  may  take  place  sufficiently  to 
allow  of  restoration  of  the  function  of  the  bone  whilst 
the  sequestra  are  retained ;  i.e.,  the  mass  of  new  bone 

thrown  out  from 
the  outer  surface 
of  the  living  por- 
tions of  the  frag- 
ments and  the  soft 
tissues  around, 
may  bridge  over 
the  gap  that  holds 
the  sequestra,  so 
extensively  as  to 
leave  but  one  or 
more  narrow  aper- 
tures (cloacse)  for 
the  escape  of  the 
purulent  dis- 
charge from  the 
granulations 
within. 

So  long  as  the 
sequestra   remain 

Fig.  25.— Diagram  of  Detacliment  of  a  Necrosed  ^     \  .^^       ^ 

Portion  of  Bone  magnified  300  diameters.         puratlOn  Will  COn- 

o,  Necrosed  portion  of  hone;  6,  living  bone  ;  c,  new    tinue  \  but        if 

formation  in  the  Haversian  canals  by  wJiicJi  the  ^ 

bone  is  detached.    iAfter  Billroth.)  sequestrotomy   be 

performed,  even 
after  the  lapse  of  years,  the  sinuses  will  close  and 
the  case  end  favourably.  Nature  is  unequal  to 
the  liberation  of  the  dead  pieces,  for  before  they 
are  detached  a  mantle  of  new  bone  has  been  de- 
posited around  them,  and  the  sinuses  have  con- 
tracted too   much   to  allow  of  their  extrusion  by  the 


pressure 


of 


the    granulations. 


The   casinsf  of  new 


Chap.  XXV.]       Spontaneous  Fracture.  193 

bone  becomes  very  thick  and  dense,  and  the  cavities 
left  after  removal  of  the  sequestra  fill  up  slowly  on 
account  of  the  dearth  of  vessels.  The  sequestra  are 
quite  characteristic.  They  present  at  one  end  a 
brittle  fracture,  at  the  other  a  worm-eaten  appearance. 

Sponta-neous  fracture. — By  this  we  mean 
that  the  fracture  results  from  an  injury  wholly 
inadequate  to  the  breaking  of  a  healthy  bone.  The 
force  is  almost  always  applied  indirectly.  The  fracture 
sometimes  occurs  without  the  knowledge  of  the  patient. 

Causes. — (a)  More  or  less  general.  1.  Senile 
osteoporosis.  Here  the  bones  are  very  brittle,  the 
compact  tissue  is  wasted,  and  the  spaces  of  the 
cancellous  tissue  are  large  and  filled  with  fat.  2. 
MoUities  ossium.  In  this  disease  the  fractures  are 
usually  multiple.      3.   Rickets.     4.   Cha,rcot's  disease. 

(b)  Local  causes.  1.  Absorption  of  the  bone 
by  a  new  growth,  or  the  pressure  ayi  an  aneurism. 
2.  Congenital  syphilitic  dystrophia,  causing  separation 
of  the  epiphyses.  3.  Syphilitic  gummata.  4.  Fatty 
atrophy  from  disease,  e.g.,  in  long-standing  joint- 
afiections.  5.  Alteration  in  the  angle  that  the  neck 
of  the  femur  makes  with  the  shaft  in  old  people. 
This  places  the  bone  at  a  mechanical  disadvantage 
when  force  is  applied  to  the  long  arm  of  the  lever. 
(The  fulcrum  is  at  the  hip.  joint,  and  the  resistance  at 
the  seat  of  fracturei) 


CHAPTER  XXY. 

INJURIES   AND    DISEASES    OF    THE    SCALP. 

Cirsoid  aneurism,  nsevus,  atheromatous  cysts,  and 
subaponeurotic  cellulitis  are  described  elsewhere.  The 
parasitic  diseases  are  beyond  the  scope  of  this  work. 

N 


194        .  Surgical  Pathology.  [Chap.  xxv. 

HeEematoma. — Hsematoma  is  an  extravasation 
of  blood  sufficient  in  quantity  to  give  rise  to  a  boggy 
or  fluctuating  swellinsf.  There  are  two  forms  of 
cephalhcematoma,  subpericranial  and  subaponeurotic. 
In  the  former  the  effusion  is  beneath  the  periosteum  ; 
in  the  latter,  beneath  the  tendinous  expansion  of  the 
occipito-frontalis  muscle.  Subpericranial  hjematoma 
is  limited  to  the  bone  over  which  it  commences, 
for  the  periosteum  is  too  firmly  fixed  at  the  sutures  to 
allow  of  its  further  separation.  Subaponeurotic 
hsematoma,  whilst  usually  confined  to  a  circumscribed 
area,  is  occasionally  difiused  over  the  cranial  vertex 
from  the  superior  curved  line  behind  to  the  brow  and 
root  of  the  nose  in  front.  It  is  impossible  to  tell  by 
manipulation  whether  a  localised  haematoma  is  beneath 
the  pericranium  or  aponeurosis.  Necrosis  is  more 
likely  to  follow  the  former,  but  it  is  not  common  in 
either  case,  unless  the  bone  is  severely  injured,  for  the 
vascular  supply  is  chiefly  derived  from  the  meningeal 
arteries.  The  extravasated  blood  passes  through 
the  usual  process  of  disintegration  prior  to  absoi-p- 
tion. 

But  whilst  there  is  yet  fluctuation,  inflammatory 
lymph  is  efi'used  at  the  base  and  margin  of  the 
swelling,  so  that  the  latter  is  surrounded  by  a  vascular 
granulation  membrane.  The  exudation  from  this 
mingles  with  the  liquefying  clot,  and  it  may  end  in 
suppuration  but  more  frequently  it  is  reabsorbed. 
The  inflammatoi'y  induration  terminates  abruptly  on 
the  side  of  the  hsematoma,  whereas  it  gradually  sub- 
sides into  the  soft  structures  beyond.  As  the  finger 
is  passed  from  without  in,  it  comes  upon  a  sharp 
declivity  at  the  edge  of  the  crateriform  inclosure. 
This  gives  one  the  idea  of  a  depressed  fracture ;  but 
it  will  be  found  that  the  floor  of  the  apparently 
sunken  space  lies  in  the  natural  curve  of  the  skull. 
In  the  end  there  is  complete  levelling  by  absorption 


Chap.  XXV.]       Diseases  of  the  Scalp.  •       195 

of  the  superabundant  lymph,  and  the  normal  condition 
is  restored. 

Pott's  pufiy  tiimoiir.     [Vide  Necrosis.) 

Scalp  wounds. — The  large  number  of  arteries 
in  the  scalp,  and  their  very  free  anastomosis,  explain 
at  once  the  profuse  bleeding,  the  wonderful  power  of 
repair  of  wounds,  and  the  great  rarity  of  sloughing. 
As  the  divided  vessels  are  embedded  in  firm,  closely- 
woven  tissue,  contraction  and  retraction  are  impeded, 
and  hence  mechanical  means  are  usually  required  to  / 
stop  the  haemorrhage. 

Erysipelas  of  tlie  scalp  is  either  idiopathic  or 
traumatic.  It  is  accompanied  by  a  good  deal  of  oedema, 
which  causes  marked  bogginess.  It  may  lead  to  sup- 
puration beneath  the  aponeurosis.  Unless  accompanied 
by  fracture  of  the  skull,  meningitis  is  a  rare  sequel, 
but  it  may  arise  from  spreading  of  the  inflammation  in 
the  course  of  the  communications  between  the  cerebral 
sinuses  and  the  external  veins.  The  severe  nervous 
symptoms  frequently  exhibited  are  in  the  majority  of 
cases  dependent  on  functional  disturbance  set  up  by  the 
poison  circulating  in  the  vessels.  It  is  thought  by 
some  that  the  tissues  of  the  scalp  are  peculiarly  liable 
to  erysipelatous  inflammation,  but  the  explanation 
probably  lies  in  the  frequency  of  scalp  wounds.  Simple 
inflammatory  redness  and  oedema  may  be  mistaken 
for  the  specific  disease, 

Tumoiu'S  of  the  scalp. — The  most  common  are 
nsevus,  sebaceous  cysts,  and  epithelioma.  When  a 
sebaceous  cyst  suppurates,  obstinate  ulceration  with 
the  growth  of  fungoid  granulations  may  simulate 
epithelioma,  but  the  history  of  the  case,  and  the 
presence  of  other  unbroken  cysts,  are  points  that 
serve  to  clear  up  the  diagnosis.  The  ^pulsating 
svjellings  comprise  hernia  cerebri,  meningocele  and 
encephalo-meningocele,  cirsoid  aneurism,  malignant 
tumours  communicatinsr  or  not  with  the  interior  of 


196       *  Surgical  Pathology.        [Chap.  xxvl 

the  skull,  and,  very  rarely,  subaponeurotic  collections 
of  pus,  blood,  or  cerebro-spinal  fluid,  receiving  the 
pulsations  of  the  brain  through  the  cleft  of  a  fracture. 
(Pulsation  of  the  scalp  without  tumour  is  seen  at  the 
fontanelles,  and  very  rarely  where  the  bone  is  exten- 
sively absorbed  in  craniotabes. ) 


CHAPTER  XXVI. 

HERNIA  CEREBRI HAEMORRHAGE    BETWEEN   THE    SKULL 

AND  DURA  MATER. 

Hernia  cerebri  is  a  protrusion  through  an  open- 
ing in  the  cranial  walls  of  a  soft  mass,  composed  of 
highly  vascular  granulation  tissue  and  softened  brain 
substance.  It  essentially  depends  on  inflammation  of 
the  meninges  and  cerebral  cortex.  It  is  most  common 
after  compound  fracture  with  laceration  of  the  dura 
mater.  The  idea  that  pressure  of  the  dura  mater 
against  the  edge  of  the  inner  table  is  sufficient  of 
itself  to  set  up  ulceration  is  erroneous ;  for  this  does 
not  happen  in  cases  of  trephining,  where  the  operation 
is  performed  for  other  than  depressed  fracture  or 
intracranial  suppuration ;  or,  in  other  words,  where 
the  soft  structures  are  neither  torn,  nor  weakened  by 
acute  inflammation. 

The  outward  pressure  of  the  brain  intermits  with 
its  pulsations,  and  the  only  result  is  moderate  thicken- 
ing, the  same  as  when  a  corn  is  produced  by  friction. 
In  hernia  cerebri  the  cerebral  membranes  are  destroyed 
by  inflammatory  softening,  and  the  underlying  portion 
of  brain  is  infiltrated  with  liquor  sanguinis  and  leuco- 
cytes. New  capillary  blood-vessels  are  developed  in 
the  embryonic  tissue.     Inasmuch  as  absorption  does 


Chap.  XXVI.]  Hernia   Cerebri.  197 

not  keep  pace  with  exudation,  and  tlie  capacity  of  the 
cranium  is  a  constant  quantity,  the  surplus  matter 
escapes  where  there  is  least  resistance,  just  as  in 
hernia  testis  {(l-v.).  The  difficulty  with  which  the 
local  circulation  is  carried  on  accounts  for  strangula- 
tion and  rupture  of  the  thin-walled  capillaries.  The 
congestion  and  interstitial  extravasation  may  be  so 
great  that  the  hernial  protrusion  closely  resembles  a 
blood  clot.  Microscopical  examination  reveals  vast 
numbers  of  leucocytes,  dilated  capillaries,  apoplectic 
effusions,  and  disintegrating  nerve-cells.  The  last- 
named  are  recognised  by  their  size  and  shape.  As  a 
rule,  the  morbid  process  only  ceases  with  the  death 
of  the  patient.  If  recovery  takes  place  the  mass 
shrinks  and  undergoes  cicatricial  contraction.  The 
fibrous  tissue  forms  a  scar,  and  fills  up  the  opening ; 
sometimes  it  is  partially  converted  into  bone. 

Should  the  patient  survive  the  loss  of  a  con- 
siderable portion  of  the  brain,  the  skull  adajjts  itself 
to  its  diminished  contents  by  hypertrophy  of  the 
diploe  and  retrocession  of  the  inner  table,  or  by  re- 
modelling without  increase  in  the  thickness  of  its  walls. 
In  the  latter  case  the  cranium  loses  its  symmetrical 
outline. 

Hernia  cerebri  pulsates  synchronously  with  the 
beats  of  the  heart. 

Hsemorrliage  between  the  skull  and  dura 
matei\ — This  is  met  with  in  many  cases  of  injury. 
Separation  of  the  dura  mater  is  effected  in  the  first 
instance  by  the  violence  of  the  blow,  but  from  this 
cause  alone  it  is  not  very  extensive.  It  is  necessarily 
accompanied  by  haemorrhage  from  the  torn  vessels  ; 
but  unless  there  be  fracture  of  the  skull,  the  bleeding 
is  seldom  profuse.  In  due  course  the  extravasated 
blood  is  absorbed,  or  suppuration  is  established  about 
the  clot.  When  the  middle  meningeal  artery  is 
wounded,  the  consequence  is  far  more  serious,  since 


198  SUR  GICA  L    Fa  T ho  logy.  [Chap .  XXV 1 1 . 

the  pressure  under  which  the  blood  is  poured  out  is 
sufficient  to  strip  up  the  dura  mater  to  a  very  consider- 
able extent,  and  the  bleeding  may  not  cease  until  a 
large  effusion  has  taken  place. 

The  appearance  of  the  clot  when  removed  with  the 
dura  mater  is  quite  characteristic.  It  is  saucer- shaped, 
the  outer  convex  surface  corresponding  with  the  con- 
cavity of  the  skull.  The  whole  preparation  bears  a 
resemblance  to  a  placenta  with  a  portion  of  the 
membranes  attached.  The  size  varies  in  most  in- 
stances from  two  to  five  inches  in  diameter,  and  from 
half  an  inch  to  an  inch  and  a  half  in  thickness.  The 
colour  depends  upon  the  time  that  elapses  between 
the  injury  and  the  death  of  the  patient,  upon  the 
degree  of  post-mortem  change,  and  upon  the  mode  of 
preserving  the  specimen.  It  may  be  dark  -  red, 
greenish-black,  or  jet-black. 

The  likeness  to  a  melanotic  malignant  tumour  is 
sometimes  very  striking,  but  it  need  never  be  mis- 
taken for  this  if  the  uniform  shape  of  the  mass  and 
the  presence  of  a  broad  expanse  of  fibrous  membrane 
(dura  mater)  be  borne  in  mind. 

As  the  large  meningeal  vessels  are  more  intimately 
connected  with  the  dui-a  mater  than  the  subjacent 
bone,  they  are  carried  inwards  by  the  clot ;  and  the 
greatest  difficulty  may  be  experienced  in  detecting  the 
situation  of  a  wound  in  the  bleeding  artery  at  the 
bottom  of  the  cavity ;  in  fact,  this  may  be  impossible. 


CHAPTER   XXVIL 

INTEACRANIAL    SUPPURATION. 

May  be  located  : — (1)  between  the  dura  mater 
and  the  skull ;  (2)  in  the  arachnoid  space  :  (3)  on  the 
surface  of  the  brain,  beneath  the  arachnoid  ]  (4)  in 


Chap. XXVII.]  Intracranial  Suppuration.  199 

the  substance  of  the  brain  (cerebral  abscess).  It  has 
been  ah-eady  noted  that  pus  may  be  formed  as  a  con- 
sequence of  injury  separating  the  dura  mater.  This 
is  quite  certain  to  be  the  case  if  the  bone  becomes 
necrosed.  Fracture  is  not  essential  for  its  occurrence. 
It  not  infrequently  happens  that  a  patient  recovers 
from  the  immediate  effects  of  the  concussion,  and 
remains  free  from  any  marked  symptom  for  several 
days,  or  even  two  or  three  weeks ;  and  that  then 
headache,  fever,  and  local  tenderness  and  swelling, 
point  to  the  probability  of  intracranial  suppuration. 

The  exact  situation  of  the  lesion  as  to  its  depth 
from  the  surface  cannot  be  determined  with  certainty 
by  the  symptoms  alone.  If,  at  the  bottom  of  a  scalp- 
wound  or  abscess,  the  bone  is  dead  and  bare,  the 
chances  are  that  there  is  pus  between  the  skull  and 
dura  mater,  with  or  without  more  deeply-seated  mis- 
chief. If  the  inner  table  has  preserved  its  vitality, 
there  may  still  be  suppuration  immediately  beneath 
it;  or,  the  dura  mater  remaining  adherent,  localised 
or  diffuse  abscess  may  be  found  in  the  arachnoid 
cavity.  In  a  case  of  gun-shot  injury  to  the  skull, 
without  fracture,  I  found  a  few  drops  of  pus  external 
to  the  dura  mater,  and  a  collection  between  the 
parietal  and  visceral  layers  of  the  arachnoid  over  a 
surface  of  about  three  inches  in  diameter. 

Interarachnoid  suppuration  is  either  local  or  gene- 
ral. The  event  turns  mainly  on  the  intensity  and 
rapidity  of  the  inflammatory  process.  Where  these 
are  moderate  in  degree,  the  opposed  surfaces  at  the 
periphery  of  the  inflamed  area  are  united  by  plastic 
lymph,  and  a  boundary  wall  is  thus  formed  which 
prevents  the  diffusion  of  the  pus.  Abscess  of  the 
brain,  the  result  of  injury,  is  sometimes  found  with- 
out a  trace  of  suppuration  in  the  arachnoid  or  outside 
the  dura  mater. 

Purulent    effusion    between   the    bone    and    dura 


2  00  Surgical  Pathology.      [Chap.xxvii. 

mater  in  the  majority  of  cases  is  due  to  injury,  with 
or  without  fracture  or  necrosis.  When  syphilitic 
caries  attacks  the  inner  table  of  the  cranial  vault,  a 
certain  amount  of  pus  exudes  from  the  granulations, 
and  either  remains  locked-up  between  the  bone  and 
the  thickened  dura  mater,  or  escapes  through  a  crevice 
by  the  side  of  a  sequestrum. 

In  meningitis  from  disease  of  the  middle  ear  and 
petro-mastoid  cells,  the  dura  mater  is  generally  found 
in  a  sloughy  condition  ;  there  can,  however,  be  little 
doubt  but  that,  previously  to  its  perishing  in  this 
manner,  suppuration  to  a  limited  extent  occurs  be- 
neath it. 

Siippisrattve  aractiiiitis  is  extremely  rare, 
except  as  a  consequence  of  inflammation  spreading 
from  the  bone  and  dura  mater ;  hence  a  careful  search 
should  always  be  made  for  some  local  injury  or 
disease,  such  as  caries  of  the  middle  ear,  or  syphilitic 
caries.  Now  and  then  it  occurs  as  a  metastasis,  from 
bed-sore  or  other  form  of  pyaemia,  but  the  liability  to 
septic  infection  of  the  arachnoid  is  much  less  than  is 
the  case  with  the  pericardium  or  pleura.  There  is 
sometimes  increased  secretion  in  the  arachnoid  as  a 
result  of  irritation  from  pia-meningitis  ;  but,  whilst 
the  fluid  may  be  cloudy,  it  never  attains  the  purulent 
character,  as  it  does  in  inflammation  from  the  above- 
mentioned  causes. 

Although  the  pus  is  occasionally  confined  to  the 
region  of  some  local  centre  of  disease,  it  is  generally 
difiused  through  the  whole  or  greater  part  of  the 
cavity.  It  usually  escapes  in  some  quantity  on 
incising  the  dura  mater ;  and,  when  that  membrane  is 
removed,  the  brain  is  seen  to  be  covered  with  a  thick 
layer  of  exudation,  creamy  or  yellowish-green  in 
colour. 

Fia-]aieiiing:eal  suppuration  occurs  as  an 
idiopathic  disease  in  many  instances.     This  is  notably 


Chap,  xxvii.]         Cerebral  Abscess.  201 

the  case  in  very  young  children,  who  seem  to  be  pecu- 
liarly predisposed  to  it.  The  term  "idiopathic"  is 
used,  since  the  actual  cause  is  not  well  ascertained. 
There  appears  to  be  reason  for  the  belief  that  it  is 
occasionally  the  manifestation  of  the  action  of  the 
poison  of  an  acute  specific  fever.  Those  circum- 
stances that  combine  to  produce  general  marasmus 
also  aid  in  its  causation. 

In  tubercular  meningitis  there  is  always  a  con- 
siderable amount  of  exudation  ;  this,  in  the  ventricles 
and  subarachnoid  space,  is  cloudy  and  serous,  and,  in 
the  meshes  of  the  pia  mater,  highly  fibrinous,  and 
sometimes  quite  purulent.  In  the  latter  situation  it 
appears  as  a  sulphur-like  layer  beneath  the  visceral 
arachnoid.  Tubercular  meningitis  is  most  marked  at 
the  base  of  the  brain,  idiopathic  at  the  vertex. 

Another  cause  of  pia-meningitis  is  abscess  in  the 
cerebral  cortex. 

Ceretoral  abscess  is  found  as  the  sequel  of 
injury  to  the  skull.  It  also  follows  acute  and  chronic 
suppuration  in  the  middle  ear  and  mastoid  cells.  In 
pyaemia  it  is  comparatively  rare.  The  symptoms 
depend  much  more  upon  the  locality  than  the  size  of 
the  abscess.  I  have  known  the  anterior  lobe  of  the 
brain  to  be  in  great  measure  destroyed  without  there 
being  any  indication  of  such  an  extensive  lesion. 
The  situation  of  the  abscess  may  be  suggestive  of  its 
cause.  Thus,  the  cerebellum  is  the  usual  seat  of  the 
suppuration  set  up  by  spreading  of  the  inflammatory 
process  from  the  mastoid  cells ;  next  to  this  comes 
the  temporo-sphenoidal  lobe.  As  a  rule,  traumatic 
abscess  forms  beneath  the  x>art  injured  by  a  blow. 

The  contents  of  the  abscess  consist  of  exudative 
material  and  the  debris  of  the  brain  substance, 
together  with  a  certain  amount  of  blood  extravasated 
from  the  capillaries.  They  are  prone  to  decomposi- 
tion, and  so  the  blood  pigment  is  rapidly  transformed 


202  Surgical  Pathology.      [Chap.  xxviii. 

into  derivative  compounds,  and  the  pus  variously 
coloured — deep  yellow,  reddish-brown,  or  dirty  green. 
The  odour  is  often  very  offensive,  and  this,  too, 
where  there  has  been  no  communication  with  the 
external  air.  The  walls  are  composed  of  brain  tissue, 
infiltrated  with  inflammatory  products  and  blood  that 
has  escaped  from  rupture  of  degenerated  vessels.  On 
pouring  water  over  the  surface,  fine  flocculi  float  out 
from  the  disintegrating  tissues^  except  in  cases  of 
long  standing,  where  there  is  a  kind  of  pyogenic 
membrane. 


CHAPTER   XXYIII. 

SUPPURATION   IN    THE    MASTOID    CELLS. 

By  far  the  most  common  cause  is  disease  of  the 
middle  ear,  but  it  may  arise  in  connection  with 
strumous  or  syphilitic  caries  of  the  bone.  In  the 
former  case  there  is  generally  some  discharge  from  the 
external  auditory  meatus  through  a  perforation  in  the 
membrana  tympani.  The  process  may  develop  with 
great  rapidity,  or,  on  the  other  hand,  it  may  be 
exceedingly  slow.  Not  unfrequently  months  or  years 
elapse  from  the  onset  of  otitis  media  before  there  is 
any  external  evidence  of  implication  of  the  mastoid 
cells.  The  usual  signs  are  pain  and  tenderness  at  the 
back  of  the  ear,  followed  by  redness  and  swelling, 
headache,  and  other  cerebral  disturbance.  The  facial 
nerve  is  liable  to  irritation  and  compression  as  it  lies 
in  its  narrow  channel.  This  will  be  evinced  by 
twitching  or  paralysis  of  the  muscles  of  the  face. 
Although  the  osseous  compartments  communicate 
with  one  another,  the  pus  does  not  all  escape  at 
once  when  the  external  plate  of  bone  is  destroyed  by 


Chap.  XXIX.]   Pulsation  of  the  Eye-Ball.        203 

ulceration  or  removed  by  operation,  for  soft  granulation 
tissue  blocks  more  or  less  the  openings  from  the  cells. 
Free  discharge  by  way  of  the  tympanum  is  checked 
by  swelling  of  the  lining  membrane ;  and  thus,  from 
want  of  relief  of  the  inflammatory  tension,  there  is 
great  danger  of  the  disease  spreading  through  the 
thin  laminae  that  separate  the  mastoid  cells  from  the 
dura  mater,  and  setting  up  meningitis  and  cerebral 
abscess. 

On  breaking  down  the  avails  of  the  cells  in  acute 
suppurative  ostitis,  pus  escapes  like  honey  from  the 
comb  j  but  in  caries  the  softened  bone  contains  not 
only  pus,  but  a  quantity  of  granulation  tissue  and 
caseous  debris. 


CHAPTER   XXrX. 

PULSATION    OF    THE    EYE- BALL. 

Pulsation  of  the  eye-ball  is  accompanied  by  more 
or  less  prominence.  It  is  caused  by  (1)  several 
varieties  of  aneurism,  circumscribed,  diffuse,  ruptured, 
and  cirsoid ;  (2)  very  vascular  sarcomatous  growths ; 
and  (3)  rarely  by  pulsation  of  the  vessels  in  exoph- 
thalmic goitre. 

Circumscribed  aneurism  results  from  direct  wound 
of  the  ophthalmic  artery  or  one  of  its  branches,  or  it 
arises  spontaneously.  Cirsoid  aneurism  (g.  v.)  is  some- 
times produced  by  blows,  or  concussion  of  the  skull, 
though  this  cause  cannot  always  be  assigned.  The 
morbid  process  is  probably  a  subacute  inflammatory 
thickening  and  softening  of  the  walls  of  the  arteries 
with  secondary  dilatation. 

In  sacculated  and  cirsoid  aneurism  there  is  usually 
marked  bruit,  and  there  may  be  distinct  thrill. 


2  04  Surgical  Pathology.        [Chap.  xxtx. 

Prominence  op  the  Eye-ball,  Exophthalmos. 

The  causes  of  prominence  of  the  eye-ball  may 
be  tabulated  thus  :  (1)  Enlargements  of  the  globe  : 
{a)  intraocular  tumours,  e.g.,  glioma  of  the  retina 
and  sarcoma  of  the  choroid  and  iris  ;  (h)  acute  glau- 
coma. (2)  Orbital  tumours:  (a)  vascular,  including 
aneurisms,  venous  nsevus,  and  dilatation  of  the  vessels 
in  exophthalmic  goitre ;  (b)  solid  tumours.  These 
may  arise  in  the  orbit,  or  invade  it  from  other  parts, 
e.g.,  the  maxillary  antrum,  and  the  naso-pharynx  and 
contiguous  sinuses.  (3)  Orbital  cellulitis  and  abscess. 
(4)  Absorption  or  depression  of  the  orbital  plate  of 
the  frontal  bone  in  chronic  hydrocephalus.  (5)  Para- 
lysis of  the  ocular  muscles,  as  when  a  gumma  presses 
on  the  third  nerve.  (6)  Dilatation  of  the  frontal 
sinus  from  accumulated  secretion  or  chronic  abscess. 

Orbital  cellulitis  and  abscess  may  be  due  to  fracture, 
or  syphilitic  periostitis,  or  metastasis  in  pysemia.  It 
occasionally  follows  suppurative  inflammation  of  the 
eye-ball  in  rheumatic  or  traumatic  ophthalmitis. 

It  is  recognised  by  the  severe  throbbing  pain,  and 
redness  and  oedema  of  the  eyelids. 

The  continuous  pressure  of  the  cerebro-spinal  fluid 
in  chronic  hydrocephalus  induces  atrophy  of  the 
orbital  plate,  and  at  the  same  time  causes  depression 
of  the  bone.  In  this  way  the  cavity  of  the  orbit  is 
encroached  upon,  and  the  contents  driven  forwards. 
In  extreme  cases  the  eyelids  are  unable  to  cover  the 
front  of  the  globe. 

The  straight  and  oblique  muscles  of  the  eye  by 
their  tonic  contraction  maintain  a  gentle  compression 
on  the  globe,  which  keeps  it  steadily  in  its  place. 
When  several  of  them  are  paralysed,  the  pressure  of 
the  blood-vessels  in  the  orbit,  no  longer  balanced  by 
the  usual  support  given  to  the  eye-ball,  causes  the 
latter  slightly  to  advance. 


205 

CHAPTEE,   XXX. 

INFLAMMATION     OF     BONE. 

On  account  of  its  stability  bone  tissue  presents 
a  favourable  field  for  the  study  of  inflammation  and 
other  diseases. 

Dried  specimens  preserve  indefinitely  coarse  altera- 
tions in  form  and  structure ;  and  by  softening  and 
staining,  preparations  can  be  made  that  faithfully 
picture  the  more  minute  changes  in  nutritive  and 
formative  activity. 

Bone  consists  essentially  of  a  rigid  calcified  frame- 
work, passive,  but  none  the  less  important  in  the 
production  of  morbid  states  ;  and  of  soft  tissues 
modified  here  and  there  according  to  the  function  they 
are  called  upon  to  perform.  Taking  a  long  bone,  there 
is  a  layer  of  cartilage  covering  the  articular  ends ;  a 
highly  vascular  periosteum  subserving  nutrition  and 
growth ;  a  soft  medulla  accumulated  in  the  central 
canal,  continuous  with  that  which  forms  a  bed  for  the 
vessels,  in  the  open  network  of  the  cancellous  tissue 
and  the  narrow  channels  of  the  Haversian  canals.  All 
this  in  the  foetal  state  is  red,  but  at  a  later  period  the 
cells  of  the  central  medulla  and  of  the  cancellous 
tissue  become  loaded  with  fat,  giving  these  structures 
a  yellow  appearance.  Then  there  is,  up  to  a  certain  age, 
a  layer  of  developmental  cartilage  between  epiphysis 
and  shaft. 

It  may  be  noted  that  the  marrow  of  certain  bones 
{e.g.^  vertebrae,  sternum,  and  ribs)  retains  more  or  less 
its  foetal  condition  throughout  life.  For  the  main  part 
the  red  medulla  consists  of  embryonic  cells,  in  which 
are  imbedded  huge  multinucleated  corpuscles  and 
delicate-walled  blood-vessels. 


2o6  Surgical  Pathology.         [Chap.  xxx. 

The  relative  porosity  of  different  parts  of  the  same 
bone  will  to  a  great  extent  determine  the  issue  of 
inflammatory  and  other  processes ;  thus,  in  the  open 
fretwork  of  the  cancellous  tissue,  passive  congestions, 
chronic  exudations,  caseation,  and  absorption  of  the 
osseous  lamellae  (the  sum  total  of  which  is  caries), 
find  a  more  suitable  nidus  than  in  the  compact  bone, 
whose  channels  are  so  small  that  the  blood-vessels 
readily  become  compressed,  with  consequent  immediate 
death  of  the  part  (necrosis). 

Causes. — Ostitis  may  be  caused  by  traumatism, 
or  by  some  morbid  material  in  the  blood  irritating  the 
medullary  constituent  of  bones,  e.g.,  of  syphilis,  the 
acute  specific  fevers,  pyaemia,  and  rheumatism.  In 
struma  the  carious  process  often  follows  some  slight 
injury,  though  frequently  no  local  origin  can  b© 
assigned,  and  when  it  can  the  destructive  changes  are 
out  of  proportion  to  the  intensity  of  the  irritation. 

Then  there  are  the  so-called  idiapathic  inflamma- 
tions that  are  attributed  to  exposure  to  wet  and  cold, 
or  some  more  obscure  source  ;  the  real  cause  being  pro- 
bably what  we  term  a  predisposition,  i.e.,  some  diseased 
state  of  the  blood,  or  bone,  or  both,  suflicing  to  start 
the  inflammation,  but  recognised  only  by  its  results. 

Terminations. — Ostitis  may  terminate  (1)  in 
molar  death,  or  necrosis  ;  (2)  molecular  death,  or 
caries ;  (3)  sclerosis,  or  condensation.  The  same 
specimen  often  shows  all  three;  e.g.,  the  lower  end  of 
the  femur  in  strumous  arthritis,  where  the  articular 
surface,  denuded  of  its  cartilage,  looks  woiTQ-eaten,  and 
the  cancellous  structure  of  the  epi23hysis  appears 
rarefied  from  absorption  by  granulation  tissue,  whilst 
occupying  a  cavity  in  the  interior  may  be  seen  a 
sequestrum,  and  on  the  surface  numerous  stalactitic 
deposits  of  new  bone.  As  to  which  shall  predominate, 
one  has  to  look  (1)  to  the  intensity  of  the  inflammation; 
(2)  to  the  cause,  whether  it  be  local  or  general ;  (3)  to 


Chap.  XXXI.]     Rarefying  Ostitis — Caries.         207 

the  density  of  tlie  bone.  The  exudation  may  he  so 
excessive  as  to  lead  to  an  acute  interruption  in 
nutrition  by  strangulation  of  the  vessels,  and  this  will 
occur  the  more  readily  if  the  spaces  that  contain  the 
latter  are  small,  as  in  the  Haversian  canals  of  com- 
pact bone;  hence  the  frequency  of  necrosis  from  sup- 
purative inflammation  of  the  shafts  of  long  bones. 

Constitutional  states  are  a  frequent  cause  of  necrosis, 
as  seen  in  the  rapidly  destructive  inflammation  of  the 
growing  part  of  bone  in  children,  and  in  the  more 
chronic  lesions  of  syphilis  and  scrofula ;  but  the  part 
that  they  play  in  the  history  of  caries  is  all  important, 
for  the  same  conditions  that  favour  the  onset  act  also 
against  the  possibility  of  repair  ;  if  the  vitality  of  the 
tissues  is  so  low  as  to  be  unable  to  meet  the  physio- 
logical calls  for  maintenance  and  repair,  how  can  it  be 
expected  to  be  equal  to  the  extra  task  of  re-construction 
after  the  ravages  of  disease  1 

C ceteris  paribus,  the  same  cause  (e.^.,  syphilis), 
varying  in  intensity  at  difierent  times,  will  lead  to 
corresponding  results;  thus,  an  ossifying  node  of  the 
tibia,  caries  of  the  skull,  and  necrosis  of  the  nasal 
bones,  may  form  a  natural  sequence  in  the  same 
subject,  or  each  may  be  found  alone. 

Again,  the  outcome  of  one  source  of  irritation  may 
in  its  turn  create  another,  as  when  a  sequestrum  sets 
up  a  formative  ostitis,  or  caries  entails  necrosis,  or 
necrosis,  caries. 


CHAPTER    XXXI. 

RAREFYING     OSTITIS CARIES. 

Next  to  necrosis  in  order  of  severity  is  that  form 
of  destruction  of  bone  commonly  known  as  "  caries," 
"  molecular  death,"    or    ''  ulceration,"    in  which  the 


2o8  Surgical  Pathology.        [Chap.  xxxi. 

earthy  and  animal  constituents  are  slowly  disintegrated 
and  removed.  This  is  effected  by  the  absorbent  action 
of  granulation  tissue. 

The  word  "  caries "  usually  implies  something 
more  than  mere  inflammatory  softening  and  porosis ; 
it  raises  the  question  of  caseation  and  chronic  sup- 
puration, with  their  local  and  general  consequences.  I£ 
the  terms  caries  and  rarefying  ostitis  are  considered  as 
synonymous,  several  forms  of  inflammatory  rarefaction 
of  bone  (simple,  scrofulous,  tubercular,  and  syphilitic) 
more  or  less  distinct  in  their  origin,  course,  and  ter- 
mination, are  included  in  the  same  category.  It 
would  be  well  to  discard  the  word  "  caries "  alto- 
gether, and  to  describe  separately  each  variety  of 
rarefying  ostitis. 

Cornil  and  Ranvier  maintain  that  rarefying  ostitis 
is  only  a  stage  of  caries,  and  secondary  to  a  charac- 
teristic lesion,  viz.,  "  a  fatty  change  destructive  of 
the  cells  contained  in  the  lacunae," 

They  recognise  two  distinct  periods  in  caries  ;  "in 
the  first  the  bone  cells  undergo  fatty  degeneration 
without  there  being  previously  the  least  sign  of  in- 
flammation ;  in  the  second,  the  osseous  trabeculse, 
killed  by  the  death  of  their  cellular  elements,  form  so 
many  foreign  bodies  which  determine  suppurative 
inflammation  around  themselves." 

But  they  do  not  assign  any  reason  for  the  primary 
degeneration  of  the  bone  corpuscles,  nor  explain  why 
their  death  should  kill  the  osseous  trabeculse.  It 
is  not  usual  for  fatty  degeneration  to  set  up  in- 
flammation, it  is  more  often  the  result  of  it ; 
and  I  am  inclined  to  believe  that  the  degeneration 
of  the  bone  corpuscles-  is  the  consequence  of  their 
death,  and  that  this  depends  on  precedent  inflam- 
mation. 

The  heart,  arteries,  and  cornea,  when  far  advanced 
in  fatty  decay  do  not  become  inflamed. 


Chap.  XXXI.]  Rarefying  Ostitis — Caries.  209 

Simple  rarefying  ostitis,  or  caries*— When 
a  bone  is  injured  the  blood-vessels  dilate,  and  there  is 
exudation  of  liquor  sanguinis  and  leucocytes.  Here 
the  process  may  end,  the  simple  ostitis  subsiding,  and 
the  bone  returning  to  its  normal  condition. 

If  the  irritation  is  more  intense,  as  in  the  case  of 
fracture,  or  if  it  is  more  prolonged,  as  when  a  seques- 
trum is  imprisoned,  the  inflammation  becomes  chronic 
and  the  exudation  continuous. 

The  vessels,  from  their  elongation,  can  only  be 
accommodated  within  the  rigid  walls  of  the  Haversian 
canals  by  forming  loops,  or  curves.  Around  these 
curves  migratory  cells  accumulate,  giving  rise  to  the 
first  appearance  of  granulations  or  buds  of  embryonic 
tissue,  which  enlarge  and  destroy  the  bone.  Hence, 
instead  of  an  even  absorption,  the  osseous  trabeculse 
are  excavated  here  and  there  in  a  festooned  manner. 

The  crypts  or  recesses  filled  with  granulation  tissue 
are  called  Howship's  lacunae. 

It  is  supposed  by  some  that  the  bone  corpuscles 
take  an  active  part  in  the  process,  dividing  and  sub- 
dividing ;  but  most  pathologists  agree  that  the  in- 
difierent  granulation-cells  (osteoclasts)  are  merely 
leucocytes  that  have  wandered  from  the  blood-vessels ; 
and  that  the  stellate  bone-corpuscles  show  little  or  no 
sign  of  formative  activity  ;  that,  in  fact,  they  undergo 
retrograde  changes,  as  may  easily  be  seen  where  opened 
lacunae  are  setting  free  their  degenerated  contents. 

There  may  or  may  not  be  suppuration  and  purulent 
discharge;  the  event  depends  mainly  upon  the  intensity 
of  the  irritation. 

A  spongy  bone  may  be  honeycombed  by  absorj)tion, 
so  that  it  can  be  divided  with  a  knife,  and  yet  not 
a  drop  of  pus  be  formed  ;  in  fact,  the  shell  of  compact 
bone  may  contain  little  but  granulation  tissue. 

This  is  what  Billroth  terms  caries  fungosa,  or 
caries  non-suppurativa.  Such  a  case,  whether  it  be 
o 


2IO 


Surgical  Pathology. 


[Chap.  XXXI. 


started  by  injury  or  arise  spontaneously,  shows  that 
the  granulation  tissue  has  sufficient  vitality  to  sur- 
vive, and  that,  instead  of  undergoing  liquefaction 
or  caseation,  it  may  at  any  time  (the  inflamma- 
tion subsiding)  organise  and  ossify  until  the  de- 
posit of  new  bone  exceeds  in  density  the  original 
structure. 

The  rarefying  ostitis  has  passed  insensibly  into  a 
sclerosing  or  condensing  ostitis. 

Strumous  rarefying  ostitis  (struuious 
caries). — This  differs  from  simple  traumatic  rarefying 


rig.  2'\ — I?arefying  Fungous  Ostitis,  from  a  case  of  Strumous  Dactylitis. 
The  inflammation  was  very  chronic.  There  is  no  caseation,  but 
here  and  there  an  attempt  at  organisation. 

4,  Bone  undergoing  absorption  by  the  granulation  tissue,  6  ;  e,  granulation  bud 
that  has  perforated  the  '  sseous  lamellis ;  d,  blood-vessel.  The  bone  cor- 
puscles show  no  signs  of  segmentation. 


ostitis,  in  that  it  arises  from  a  constitutional  cause 
alonSj  or  from   local   irritation  too   slight    to   set  up 


Chap.  XXXI.]  StRUAWUS    C ARIES.  211 

destructive  inflammation  in  a  healthy  subject.  More- 
over, it  rarely  begins  in  compact  bone. 

The  most  common  situations  are  the  tarsus  and 
carpus,  the  vertebrae  and  the  cancellous  ends  of  the 
long  bones.  The  sternum,  ribs,  and  petromastoid  bone 
are  also  frequently  affected. 

Some  cases  are  so  slight  that  the  disease  runs  its 
coarse  without  suppuration  or  caseation  (Fig,  2Q).  The 
granulation  tissue  which  fills  the  Haversian  canals, 
and  medullary  spaces,  and  eats  out  the  bony  trabecules, 
is  exuberant,  semi-gelatinous,  and  firm,  and  as  the 
inflammation  subsides  it  organises  into  connective 
tissue  and  bone.  This  is  caries  fungosa  (fungating 
ostitis). 

But  far  oftener  the  exudation  is  purulent,  and 
the  granulation  tissue  breaks  down ;  and  the  pus  and 
debris  collect  in  an  abscess  cavity  in  the  interior  of 
the  bone.  The  walls  of  the  abscess  are  composed  of 
inflamed  disintegrating  bone,  and  are  lined  with 
caseous  pus. 

The  abscesses  may  remain  closed  indefinitely,  but, 
as  a  rule,  they  open  into  a  contiguous  joint,  or  ex- 
ternally. This  is  one  way  in  which  white  swelling,  or 
strumous  arthritis,  commences. 

Now  and  then  the  granulation  tissue  undergoes 
fatty  degeneration  and  caseation  without  suppuration. 

The  disease  may  be  divided  into  three  stages : 
(1)  that  of  congestion;  the  bone  is  of  a  deep  red 
or  violet  hue,  giving  one  the  idea  of  extravasation. 
This  stands  in  marked  contrast  with  the  surrounding* 
pinkish-yellow  colour  of  the  healthy  medulla ;  (2)  the 
growth  of  soft  vascular  granulation  tissue ;  (3)  de- 
generation and  softening  of  the  neoplasia,  purulent 
exudation,  and  absorption  of  the  osseous  trabeculse. 

The  bone  corpuscles  wither  and  break  up  into  fat 
molecules.  The  fat  cells  are  destroyed.  Caseation 
of  the  inflammatory  products  results  from  an  inherent 


2  12  Surgical  Pathology.        [Chap.  xxxi. 

low  vitality,  and  strangulation  and  thrombosis  of 
the  vessels.  When  the  disease  is  very  rapid,  the 
cancellous  spaces  and  Haversian  canals  are  filled  with 
pus. 

The  bone  may  be  absorbed  in  such  a  manner,  that 
a  portion  is  isolated  from  the  rest  by  a  zone  of  granu- 
lation tissue ;  then  it  usually  dies  (caries  necrotica), 
but  it  may  retain  its  vascular  connection,  and  survive 
as  a  "  living  sequestrum." 

A  section  through  a  carious  bone  {e.g.,  the  head 
of  the  tibia)  often  shows  the  A^arious  stages  of  the 
morbid  process ;  simple  congestion  at  the  periphery  ; 
next  to  this,  a  tract  of  softened  bone  infiltrated  with 
a  pinkish-grey  soft  gelatinous  material  ;  and  then 
a  pultaceous  collection  of  j^^s  and  caseous  debris, 
and  in  its  midst  a  sequestrum. 

In  central  caries  the  surface  of  the  bone  varies  j 
it  may  be  simply  thickened  from  deposit  of  new  bone, 
or  it  may  be  worm-eaten  for  some  distance,  from 
extension  of  the  i-arefying  ostitis  \  but  even  then 
osteophytes  are  thrown  out  at  the  borders. 

Superficial  rarefying  ostitis,  or  caries,  is 
due  to  the  same  causes  as  the  central  variety,  but  it 
more  often  follows  injury.  The  periosteum  and 
superficial  part  of  the  bone  are  attacked  at  the  same 
time.  The  subpeiiosteal  medulla  is  converted  into  a 
red  pulp,  which  extends  into  the  Haversian  canals  of 
the  compact  bone.  The  osseous  trabeculse  are  thinned, 
so  that  a  probe  can  be  driven  through  them.  The 
further  progress  of  the  case  depends  upon  the  intensity 
of  the  initial  irritation,  and  the  state  of  health  of  the 
patient.  It  may  pass  at  once  into  sclerosing  repara- 
tive ostitis,  or  proceed  to  suppuration  and  caseation. 
When  a  periosteal  abscess  is  opened,  the  bone  beneath, 
unless  necrosed,  is  found  to  be  more  or  less  porous. 
But  most  cases  of  superficial  caries  are  chronic  from 
the  first,  for  acute  exudation  strangulates  the  vessels 


Chap.  XXXI.]  Tubercle  of  Bone.  213 

ill  tlie  narrow  Haversian  canals  of  compact  bone,  so 
that  it  dies. 

Superficial  caries  from  injury  may  occur  in  any 
bone.  When  of  strumous  origin  it  is  found  in  the 
same  situations  as  central  caries.  It  is  not  uncommon 
in  the  malar  bone,  about  the  lachrymal  sac,  and  in 
the  mastoid  process.  Syphilitic  caries  has  a  special 
proclivity  for  the  cranial  vault,  a  place  where  stru- 
mous caries  is  rarely  seen. 

Nature  of  tlie  «liscliar§^e  ia  caries. — In 
strumous  caries  it  is  seropurulent,  or  curdy.  The 
liquor  puris  holds  in  susjDension  caseous  flakes,  pus 
cells,  granular  debris,  and  crumbs  of  necrosed  bone 
set  free  by  the  melting  down  of  the  granulation  tissue  ; 
in  solution,  lactic  acid,  and  the  usual  alkaline,  earthy, 
and  organic  constituents.  There  is  an  excess  of 
lime  salts. 

Tiitoercle  of  bone. — Some  authors  consider  all 
the  products  of  strumous  caries  as  tubercle ;  but 
reference  is  here  made  to  miliary  granulations  in 
bone ;  small,  hard  nodules,  composed  of  groups  of 
cells,  set  in  a  granular,  homogeneous,  or  fibrillated 
matrix.  The  vessels  of  the  medullary  spaces  and 
Haversian  canals  are  obliterated  by  the  growth,  which 
is  extravascular.  This  takes  place  before  the  neoplasia 
has  time  to  absorb  the  bone,  hence  those  portions  im- 
bedded in  the  tubercles  do  not  appear  notched,  as  in 
rarefying  ostitis. 

There  are  two  forms,  discrete  and  confluent.  The 
latter  is  the  result  of  the  fusion  of  isolated  tubercles. 
The  tubercles,  together  with  the  products  of  rarefying 
ostitis  around  them,  undergo  fatty  degeneration,  and 
are  lost  to  sight  in  the  caseous  debris  ;  but  the  true 
nature  of  the  case  is  shown  by  the  existfince  of 
isolated  tubercles  at  the  periphery,  and  by  examination 
of  the  bony  trabeculse. 

The  vertebrae,    sternum,    and    the    bones    of    the 


214 


Surgical  Pathology 


[Chap.  XXXI. 


carpus  and  tarsus  are  the  most  likely  situations.    It  is 
said  the  cranial  bones  are  not  affected. 

The  deposits  form  part  of  a  general  tuberculosis, 
or   they  result   from   local  infection  by  the  caseous 


Fig.  27  (one-half  natural  size). — Caries  of  the  Vertebrae,  with 
Angular  Curvature  of  the  Spine. 

a.  Body  of  vertebra,  eroded  and  rarefied  by  granulation  tissue  ;  6,  bodies  of  two 
vertebra  in  wbicb  sclerosing  ostitis  has  succeeded  to  carious  rarefaction; 
c,  neural  arches  aucbylosed.  Many  intervertebral  discs  have  been  removed 
by  absorption,  and  the  bodies  of  the  corresponding  vertebra  fused  together. 

products  of  strumous  ostitis  (caries  atonica).  They 
are  thus  at  once  the  cause  and  consequence  of  rare- 
fying ostitis. 

Caries  of  the  spine. — Pott's  disease  is  usually 
of  strumous  oriein.      It  is  often  started  by  a  blow  or 


Chap.  XXXI. 1        Caries  of  the  Spine.  215 

strain.  It  is  essentially  a  rarefying  ostitis  of  the 
cancellous  tissue  of  the  vertebrse.  It  rarely  iDegins 
in  the  intervertebral  discs.  Whilst  the  bodies  of  the 
vertebrae  are  being  absorbed,  an  osteoplastic  ostitis  is 
taking  place  about  the  neural  arches.  This  is  a  con- 
servative process,  for  it  prevents  sudden  dislocation, 
and  so  saves  the  spinal  cord  from  being  crushed. 

As  the  disease  is  more  extensive  at  the  anterior 
than  the  posterior  parts  of  the  bodies,  the  excavated 
bones  fall  together,  hence  the  prominent  spines  and 
curvature. 

Appearance  of  tlie  boues. — Compare  them 
with  the  regular,  circumscribed  excavations  from  the 
pressure  of  an  aneurism  (Fig.  3),  or  an  encapsuled 
tumour,  and  with  a  spine  eaten  into  by  an  infiltrating 
sarcoma.  A  carious  spine  in  the  fresh  state  is  quite 
soft,  so  that  a  probe  can  be  driven  into  it.  The 
enlarged  medullary  spaces  are  filled  with  a  confused 
mass  of  granulation  tissue,  caseous  matter,  and  pus. 
In  a  dried  unmacerated  specimen  the  desiccated  debris 
Ivine-  in  the  razored  hollows  looks  like  half -set  mortar. 
By  maceration  all  this  is  removed,  and  then  the  open 
fretwork  of  rarefied  bone  gives  a  rough  representation 
of  the  festooned  outline  of  microscopical  fragments 
(Fig.  27). 

Then,  again,  there  may  be  an  abscess  by  the  side 
of  the  spine. 

In  sarcoma  the  bone  is  quite  healthy  close  up  to 
the  margin  of  the  growth  ;  and  there  are  no  firm 
caseous  patches  in  the  interstices  of  the  cancellous 
tissue. 

Fixity  of  the  spiue. — The  rigidity  during  life 
is  due  (a)  to  loss  of  the  elastic  discs,  (6)  anchylosis,  and 
(c)  reflex  spastic  contraction  of  the  spinal  muscles. 

State  of  tSie  spinal  cord. — The  cord  usually 
escapes  even  when  the  disease  of  the  bones  is  far 
advanced.     It  may  be  compressed  by  the  displaced 


2i6  Surgical  Pathology.        [Chap.  xxxi. 

vertebrae ;  or  the  inflammation  may  spread  to  the 
membranes  and  set  up  a  localised  sclerosis  of  the  cord; 
or  serous  effusion  into  the  theca  may  compress  the 
cord.  As  the  motor  columns  lie  near  the  bodies  of 
the  v-ertebrse,  paralysis  of  motion  comes  on  earlier,  is 
more  marked,  and  often  occurs  without  paralysis  of 
sensation. 

The  ciu'vatiire  of  the  spine  (kyphosis)  is 
angular,  for  the  disease  is  mostly  confined  to  a  few 
vertebrae.  In  rickets  and  chronic  rheumatic  disease 
the  curves  are  uniform. 

ISpiiial  a.fescesses  (retropharyngeal,  mediastinal, 
psoas,  lumbar,  etc.)  are  often  very  large.  They 
m.ay  dry  up,  leaving  a  cheesy  residuum.  At  a  later 
period  suppuration  may  start  afresh  at  the  seat  of  the 
previous  disease — residual  abscess.  {Vide  Chronic 
abscess.) 

Process  of  cure. — As  the  disease  subsides 
osteoplastic  ostitis  succeeds  the  caries,  and  in  the  end 
the  eroded  vertebrae  are  fused  into  a  mass  of  bone 
much  denser  than  the  original  cancellous  tissue.  Less 
commonly  bars  are  seen  to  bridge  over  the  hollows 
caused  by  absorption,  which  are  not  entirely  filled  in. 

It  differs  from  united  fracture  of  the  bodies  of 
vertebrae,  for  whilst  in  caries  the  intervertebral  discs 
are  to  a  great  extent  destroyed,  in  fracture  they 
remain  quite  healthy  close  up  to  the  circumscribed 
compact  ossified  callus. 

Sypliilitic  caries  and  necrosis. — Syphilitic 
caries  affects  principally  the  tibia,  cranium,  nasal, 
bones,  palatine  arch,  and  sternum.  It  begins  as  a 
periostitis  and  superficial  ostitis,  or  as  a  gummatous 
tumour  in  the  substance  of  the  bone.  The  osseous 
traV)eculae  are  absorbed  in  the  same  manner  as  in 
simple  rarefying  ostitis.  In  the  cranial  vault  there 
are  frequently  a  number  of  these  deposits,  which  are 
slowly  absorbed  either  spontaneously  or  as  the  result 


Chap.  XXXI.]  Syphilitic  Caries  and  Necrosis.  217 


of  treatment.  The  loss  of  substance  is  not  made 
good,  so  that  permanent  depressions  are  left  in  the 
outer  table,  and  these  are  increased  in  depth  by  the 
heaping  up  of 
new  bone  around 
them.  But  there 
is  a  more  formid- 
able form,  in 
which  the  caries 
spreads  over  a 
wide  surface,  and 
gives  it  a  pecu- 
liar, worm-eaten 
appearance.  Like 
the  nodular  form 
of  the  disease,  it 
ma  J  occur  with 
or  without  sup- 
puration. It 
sometimes  ex- 
tends throucrh  the 
entire  thickness 
of  the  bone,  so 
that  the  inner 
plate  is  as  irregu- 
lar as  the  outer. 

When  the  inflammation  is  more  intense  the  vessels 
are  obliterated  to  such  an  extent  that  the  affected 
portion  dies.  Fig.  28  shows  a  carious  sequestrum. 
It  is  surrounded  by  a  narrow  trench,  which  in  the 
recent  state  was  filled  with  granulation  tissue. 
According .  to  Yirchow  these  sequestra  are  invari- 
ably the  consequence  of  acute  strangulation  of  the 
vessels.  Cornil  and  Eanvier  maintain  that  they 
sometimes  result  from  an  excessive  interstitial  de- 
posit of  new  bone,  which  goes  on  until  the 
Haversian    canals  are    completely    filled.       It  seems 


Fig,  28. — Syphilitic  Disease  of  the  Craninm, 

a,  Ossified  node  ;  6,  sequestrum  ;  c,  carious  surface 
of  settuestrum ;  d,  apertures  formed  by  detachment 
of  sequestra. 


2i8  Surgical  Pathology.        [Chap.  xxxi. 

strange  that  an  osteoplastic  ostitis  should  entail 
necrosis. 

Total  necrosis  of  the  diaphysis  of  a  bone  as  the 
result  of  syphilis  is  very  rare.  Fig.  33  represents 
two  tibiae  from  the  same  leg.  The  original  shaft  (a) 
separated  sjjontaneously  after  necrosis.  It  was  re- 
placed by  a  new  one.  (b)  The  patient,  a  woman  cet. 
22,  died  from  acute  yellow  atrophy  of  the  liver  ten 
years  later. 

Necrosis  coBitrasted  witli  caries. — 1.  The 
part  affected. — Caries  is  more  common  in  cancellous 
tissue^  necrosis  in  compact.  The  blood-vessels  are 
better  supported  in  compact  bone,  and  so  less  liable 
to  passive  congestion ;  but  from  the  narrowness  of  the 
canals  they  are  quickly  strangulated  by  the  pressure 
of  the  exudation,  and  so  the  bone  is  rapidly  and 
completely  deprived  of  its  vitality.  In  cancellous 
bone  there  is  room  for  dilatation  and  exudation, 
without  their  causing  a  sudden  stasis  in  the  vessels. 
Moreover,  as  the  inflammation  is  less  intense,  more 
time  is  given  for  the  enlargement  of  the  vascular 
channels  by  absorption  of  the  bone. 

2.  Result  cf  probing. — In  necrosis  the  probe  is 
suddenly  arrested  by  striking  against  hard  bone,  and 
without  giving  rise  to  pain ;  whereas  in  caries  it  can 
be  felt  to  pass  through  soft  inflamed  bone,  and  this  is 
quite  sensitive. 

3.  Nature  of  the  discharge. — In  necrosis  the  dis- 
charge is  mostly  purulent ;  in  caries  it  is  more  watery 
or  serous,  and  contains  a  greater  amount  of  lactic  acid. 

4.  Granulations  along  the  sinus  and  at  its  orifice. 
— In  necrosis  they  are  comparatively  healthy,  often 
fungous  and  florid.  In  caries  they  are  small :  or  large, 
pale,  and  cedematous.  But  they  are  subject  to  so  much 
variation  that  little  reliance  can  be  placed  upon  their 
evidence. 

5.  Cause. — The  more  acute  the  cause,  whether  it  be 


Chap,  xxxii.j      Osteoplastic   Ostitis.  219 

a  local  injury,  or  constitutional  state  such  as  an  acute 
specific  fever,  the  more  likely  is  the  inflammation  to 
eacl  in  necrosis.  In  scrofula  caries  is  more  common 
than  necrosis. 

In  syphilis  both  necrosis  and  caries  are  frequent. 


CHAPTER   XXXIL 

OSTEOPLASTIC   OR    FORMATIVE    OSTITIS  AND    PERIOSTITIS. 

It  has  been  shown  that  inflammation  of  bone, 
according  to  its  severity,  leads  to  necrosis,  rarefaction, 
or  new  formation,  and  that  these  results  may  be  seen 
side  by  side  in  the  same  specimen. 

The  ossific  deposit  is  either  superficial  or  interstitial 
(internal). 

From  the  intimate  connection  between  the  perios- 
teum and  adjacent  bone,  it  is  impossible  for  one  to  be 
affected  without  the  other  being  involved  sooner  or 
later.  It  is  true  the  morbid  process  may  go  on  in  the 
periosteum  for  some  time  without  appreciable  alteration 
in  the  bone. 

Acute  inflammation  ends  in  resolution,  suppura- 
tion, necrosis,  or  it  becomes  chronic ;  chronic  leads  to 
caseation,  cold  abscess,  caries,  or  the  formation  of 
osteophytes  alone. 

Chronic  osteopla  stic  oistitis  and  periostitis 
occurs  under  many  conditions.  It  may  indicate  a  deep- 
seated  destructive  inflammation,  as  central  caries ;  or 
arise  from  injury,  or  the  irritation  of  a  chronic 
ulcer,  or  some  constitutional  state  such  as  syphilis, 
rheumatism,  etc. 

Anatomical  changes. — The  periosteum  is  at 
first  succulent   and  thicker  and  redder  than  natural. 


2  20  Surgical  Pathology.       [Chap.  xxxii. 

Tlie  fibrous  and  medullary  layers  lose  their  distinctive 
outline.  The  Tvhole  is  infiltrated  with  exudation  cells, 
and  can  be  easily  separated  from  the  bone. 

The  connective  tissue  around  the  blood-vessels  in 
the  Haversian  canals  of  the  compact  bone  is  increased 
in  like  manner.  It  is  probable  that  in  most  cases 
rarefaction  of  the  bone  takes  place  to  a  slight  extent. 
As  organisation  advances  the  periosteum  acquires  a 
greater  density,  it  has  fewer  cells,  and  these  are  more 
elongated.  Lime  salts  are  deposited  around  the 
vessels  as  they  pass  from  the  bone  to  the  periosteum, 
and  the  embryonic  cells  are  imprisoned  in  the  matrix 
as  bone  corpuscles.  The  new  osseous  trabeculse  stand 
at  rio-ht  anoies  to  the  surface  of  the  old  bone.  Whilst 
there  is  continuity  of  structure  between  the  osteophytes 
and  subjacent  bone,  the  former  can  be  easily  detached 
at  this  early  period. 

The  new  bone  is  at  the  first  quite  porous,  and  it 
may  remain  so;  but  in  some  cases  the  deposit  does  not 
cease  until  it  is  as  dense  as  ivory. 

Varieties  of  osteopliytes. — 1.  In  an  unreduced 
dislocation  a  false  joint  is  constructed,  and  to  give 
security  to  this  new  bone  is  deposited  where  the 
pi-essure  is  intermittent,  i.e.,  where  it  is  exerted  only 
in  certain  positions  of  the  more  movable  bone.  Thus, 
in  subspinous  dislocation  of  the  shoulder  the  buttress 
of  support  is  situated  on  the  dorsum  of  the  scapula. 
Here  it  is  seen  as  an  isolated  compact  mass,  looking 
as  though  it  had  been  soldered  on  to  the  healthy 
surface  from  which  it  springs,  there  being  no  sign 
of  caries  or  necrosis.  Such  an  osteophyte  is  coarsely 
furrowed  and  convex  on  one  side,  somewhat  smooth 
and  concave  on  the  other.  Its  isolation  at  once  dis- 
tinguishes it  from  chronic  rheumatic  arthritis,  which 
at  first  sight  it  resembles. 

2.  In  chronic  rheumatic  arthritis  each  bone  entering 
into  the  formation  of  a  joint  has  rounded  outgrowths 


Chap.  XXXII.] 


Osteophytes. 


221 


about  tlie  whole  articular  margin.  They  appear  as  if 
they  had  once  been  in  a  softer  condition,  and  had 
become  gradually  solidified,  for  they  droop  like  melted 
tallow  or  wax  that  has  congealed  on  cooling.  They 
really  sjrow  in  aireat  measure  from  cartilacje.  The 
articular  surfaces  are  eburnated  from  the  same 
sclerosing  ostitis  (Fig.  38). 

3.  In  strumous  arthritis  and  caries  the  extent  of 
bony  deposit  fluctuates  widely  in  different  prepara- 
tions ;  it  may  amount  to 
a  mere  roughening  of  the 
surface,  or  form  closely- 
packed  hard  craggy 
masses,  that  bear  the 
same  contrast  to  the  osteo- 
phytes of  dry  arthritis 
as  do  stalactitic  rocks  to 
water  -  beaten  boulders. 
The  articular  surface  is 
usually  porous  from 
caries  (Fig.  36), 

4.  In  chronic  ulcers 
of  the  soft  parts,  lying 
near  to  a  bone  {e.g.,  vari- 
cose ulcer  of  the  leg), 
the  deposit,  from  irrita- 
tion of  the  periosteum, 
forms  a  flattish  mass, 
gently  sloping  to  the 
healthy  bone.  The  sur- 
face is  porous,  but  fairly 
uniform. 

5.  In     rickets,     when 
the  curvature    of   a  lono- 
bone  IS  very  decided,  the 
concavity    is   occupied   by  a    beam  of    compact  bone 
thrown  out  to  support  the  arch  (Fig.  12). 


%■ 


Fig.  29. — Acicular  Outgrowths  of 
Bone  in  the  Base  of  a  Sub- 
periosteal Sarcoma  springinsr  from 
the  Epiphysis  of  a  Long  Bone. 


22  2  Surgical  Pathology.        Chap,  xxxii. 

6.  In  ossifying  'peripheral  sarcortias  of  bone,  the 
new  bone  radiates  from  the  surface  of  attachment  in 
the  shape  of  long  delicate  needle  or  spray-like  pro- 
cesses, that  bear  the  impress  of  a  centrifugal  growth 
so  characteristic  of  these  tumours.  They  are,  in  fact, 
easts  of  the  intervascular  spaces. 

7.  Bony  tumours.     (Vide  Osteomata.) 

8.  In  locomotor  ataxia.     (Vide  Trophic  lesions.) 
Nodes. — A   node    is    a    localised    inflammatory 

thickening  of  bone.  At  first  it  consists  merely  of  a 
soft  vascular  swelling  of  the  periosteum  and  surrounding 
tissues.  This  may  disappear,  or  break  down  and 
ulcerate,  or  ossify.  It  is  very  tender  on  pressure,  and 
usually  gives  rise  to  tensive  aching  pain  (vide  Pain), 
especially  at  night,  when  increased  warmth  causes  a 
fluxion  to  the  part,  and  the  patient's  attention  is 
concentrated  more  upon  himself. 

Varieties  of  nodes. — Nodes  are  classified  as 
to  their  anatomical  condition,  ossified,  carious,  etc. ; 
or  as  to  their  cause.  The  latter  basis  is  here  em- 
ployed. 

(1)  Simjole  nodes  are  due  to  injury,  and  hence  they 
are  most  common  in  the  bones  that  are  least  pro- 
tected, e.g.,  the  tibia. 

(2)  Syphilitic  nodes  are  met  with  both  in  acquired 
and  congenital  syphilis.  In  the  acquired  form  they 
may  be  located  on  any  of  the  bones,  but  the  seats  of 
election  are  the  tibiae,  cranium,  clavicles,  and  ulnse. 
As  a  rule,  they  ossify  ;  but,  if  left  untreated,  they 
frequently  break  down.  They  belong  to  the  tertiary 
stage  of  syphilis. 

They  are  simulated  by  erythema  nodosum ;  but 
the  latter  disease  afiects  younger  peoj^le,  generally 
females  ;  it  is  more  transient ;  the  part  is  movable 
over  the  bone ;  and  it  never  suppurates.  (For  de- 
scription of  congenital  syphilitic  nodes,  vide  Osseous 
lesions  of  congenital  syphilis.) 


Chap.  XXXII.]  Internal  Osteoplastic  Ostitis.     223 

(3)  Eheumatic  nodes.  Besides  the  masses  of  bone 
thrown  out  around  the  joints  in  dry  arthritis,  small 
painful  nodes  occasionally  form  in  other  parts. 

(4)  Typhoid  nodes.  During  an  attack  of  typhoid 
fever,  or  whilst  convalescence  is  being  established,  the 
periosteum  may  inflame  over  localised  areas.  These 
nodes,  like  most  others,  are  generally  situated  on  the 
tibiae.  Their  tendency  is  to  disappear ;  they  rarely 
suppurate,  and  still  more  rarely  end  in  necrosis.  In  a 
case  I  was  called  to  at  the  London  Fever  Hospital, 
the  patient,  a  young  adult  male  convalescent  from 
typhoid,  was  the  subject  of  several  recent  nodes, 
which  disappeared  after  a  short  time.  On  the  same 
bones  (tibise),  were  old  ossified  syphilitic  thickenings. 

Internal  osteoplastic  ostitis. 

Synonyms.  —  Diffuse  hypertrophy,  condensing 
ostitis,  sclerosis  ossium. 

Causes. — In  many  cases  no  cause  can  be  ascer- 
tained. In  some  there  is  a  history  of  syphilis.  I 
lately  had  under  observation  two  patients,  the  sub- 
jects of  congenital  syphilis,  in  whom  the  hypertrophy 
of  bone  was  most  marked.  In  one,  a  male  aged 
eighteen,  there  was  characteristic  notching  of  the 
teeth ;  the  tihice  were  enlarged  throughout,  much 
elongated,  and  curved  forwards ;  the  osseous  lesion 
had  existed  for  years.  The  mother  of  this  patient 
was  under  treatment  at  the  same  time  for  syphilitic 
nodes  of  the  tibise.  The  second  case  was  that  of 
a  woman  aged  twenty-two ;  the  teeth  were  notched 
and  the  cornese  nebulous  from  past  keratitis  ;  the  left 
radius  was  uniformly  rounded,  thickened,  elongated, 
and  bent  in  a  strong  outward  curve. 

There  can  be  no  doubt  but  that  these  two  patients 
suffered  from  diffuse  interstitial  ostitis ;  for  peri- 
ostitis alone,  whilst  it  would  accoim.t  for  the  circum- 
ferential enlargement,  would  not  explain  the  marked 
elongation  and  curvature. 


2  24  Surgical  Pathology.       [Chap,  xxxii. 

Ostitis  deformans. — We  are  indebted  to  Sir 
James  Paget  for  a  description  of  this  remarkable 
affection  of  the  osseous  system,  which  is  usually  found 
in  persons  past  the  prime  of  life.  It  does  not  appear 
to  be  due  to  syphilis,  as,  in  some  cases,  there  is  an 
absence  of  specific  history,  and  the  malady  runs  its 
course  unchecked  by  treatment.  It  attacks  several 
bones  at  the  same  time  or  in  sequence ;  those  of 
the  skull  and  lower  extremities  are  particularly  liable 
to  suffer.  From  the  multiplicity  of  the  lesions,  the 
disease  may  be  considered  as  one  of  the  osseous 
system  in  general,  and  not  a  chance  affection  of  one 
or  more  bones. 

The  long  bones,  e.g.,  the  femora,  are  curved  in 
spite  of  the  increase  in  thickness  ;  this  can  be  ex- 
plained by  the  fact  that  during  the  early  stages  the 
bone  is  rarefied  and  weakened  by  the  inflammation. 
At  the  end  of  the  process,  however,  there  is  marked 
increase  in  density,  and  the  medullary  cavity  of  the 
hollow  bones  is  obliterated.  The  surface  is  roughened 
from  periosteal  deposit  (Fig.  13). 

The  skull  may  be  three-quarters  of  an  inch  in 
thickness  ;  there  is  general  hypertrophy  of  the  tables, 
with  filling-in  of  the  diploe  and  obliteration  of  the 
sutures. 

The  disease  is  very  chronic,  lasting  through  many 
years,  and  during  this  time  the  general  health  may 
not  suffer.  It  is  noteworthy  that,  after  the  lapse  of 
years  in  several  instances,  the  bones  have  been  found 
to  be  the  seat  of  malignant  tumour  (sarcoma). 
Butlin's  observations  show  that  the  initial  lesion  is 
inflammatory. 

Hypertrophy  of  tlae  facial  bones,  pelvis, 
etc. — Billroth  says,  "  In  such  cases  the  bony  deposits 
are  spongy,  puffed,  nodular,  so  that  the  bone  acquires 
a  resemblance  to  skin  affected  with  elephantiasis." 
The  etiology  is  quite  obscure 


Chap.  XXXIII.]       Acute  Periostitis.  225- 

Senile    thick ening^  of  the  skull.  —  In   old 

people  the  cranial  bones  are  often  thicker  and  denser 
than  normal  j  the  diploe  is  replaced  by  solid  bone.  It 
is  probably  of  the  nature  of  a  nutritive  degeneration 
(like  enlargement  of  the  prostate),  with  increased 
formative  activity. 


CHAPTER   XXXIIL 

ACUTE    SUPPURATIVE    PERIOSTITIS,  OSTITIS,  AND 
OSTEOMYELITIS. 

When  it  is  remembered  that  there  is  direct 
structural  continuity  between  the  periosteum  and 
the  medulla  contained  in  the  Haversian  canals  of 
compact  and  cancellous  bone,  and,  in  the  case  of  the 
hollow  bones,  that  of  the  central  cavity  as  well,  it  is 
no  matter  of  surprise  that  acute  inflammation  begin- 
ning in  one  or  other  of  these  situations  should  spread 
through  the  entire  tract. 

Acute  suppurative  or  phlegmonous  periostitis  can- 
not occur  without  ostitis ;  osteomyelitis  almost  to  a 
certainty  entails  periostitis ;  yet,  for  clinical  purposes, 
it  is  found  convenient  to  treat  of  them  separately. 

Acute  periostitis  and  periosteal  abscess. 
— The  periosteum  consists  of  two  layers.  "  The  deeper, 
which  is  applied  to  the  bone,  is  formed  of  delicate 
fibres  of  elastic  and  white  connective  tissue  ;  it  forms 
a  kind  of  aponeurosis.  The  superficial  stratum  is 
much  looser  in  texture,  and  i*s  made  up  of  an  areolar 
meshwork,  in  which  the  vessels  ramify  and  anastomose 
before  penetrating  the  bone.  It  is  in  this  tissue  that 
acute  periostitis  usually  begins.  At  first  it  is  swollen 
and  red  from  vascular  congestion ;  this  is  quickly 
followed  by  a  rapid  exudation  of  leucocytes  and  liquor 
p 


2  26  Surgical  Pathology.      [Chap.  xxxiii. 

sanguinis,  so  that  the  membrane  is  converted  into  a 
purplish  pulp.  The  formed  elements  melt  away,  and 
the  debris  mingling  with  the  purulent  exudation  from 
the  vessels,  the  abscess  is  fully  formed.  Thus  we  see 
that  the  periosteum  is  destroyed  by  the  inflammatory 
process,  which  meanwhile  has  spread  to  the  surround- 
ing soft  parts  (muscle,  cellular  tissue,  skin,  etc.),  and 
has  made  them  highly  oedematous. 

The  wall  of  the  abscess  is  bounded  below  either 
by  bare  bone  or  granulations,  and  superficially  by  a 
layer  of  inflamed  tissue.  At  the  same  time,  the 
superficial  portion  of  the  bone  is  infiltrated  with 
pus  cells,  and  part  of  the  exudation,  collecting  on  the 
surface,  raises  the  periosteum  ere  the  fibrous  layer 
has  completely  softened  (periosteal  abscess).  This  is 
the  explanation  of  the  so-called  "burrowing  of  pus 
and  stripping-ofi"  of  the  periosteum." 

When  the  bone  is  deeply  seated,  an  enormous 
accumulation  of  pus  may  form  around  it.  When 
superficial  (e.^.,  the  anterior  part  of  the  tibia)  the 
abscess  usually  points  quite  early.  In  some  cases  the 
process  is  so  acute  that  beads  of  pus  may  be  seen 
on  cutting  into  the  inflamed  part  within  thirty-six 
hours  from  the  onset  of  the  disease. 

When  due  to  injury,  the  abscess  is  usually  localised. 
When  arising  from  constitutional  causes,  it  is  often 
very  difiuse ;  this  is  notably  the  case  in  children. 

Terminations.  —  The  periosteum  may  be  de- 
stroyed over  a  considerable  area,  and  yet  the  bone 
survive  ;  but  the  cutting  off  of  the  blood  supply  from 
the  surface,  and  the  great  tension  on  the  vessels  in 
the  compact  tissue,  place  it  in  imminent  peril  of 
death. 

Early  and  free  incisions  by  draining  off  the 
exudation  and  unloading  the  engorged  vessels  may 
prevent  suppuration. 

Even  when  pus  has   formed,   resolution  is  some- 


Chap.  XXXIII.]   Osteomyelitis^  Osteophlebitis.    227 

times  rapid  and  complete  after  the  bursting  or  opening 
of  the  abscess.  In  such  cases  the  granulation  tissue 
that  bounded  the  purulent  collection  superficially 
applies  itself  to  the  bone,  and  organises  into  a  new 
periosteum. 

There  is  probably  in  all  cases  a  certain  amount 
of  new  bone  deposited  on  the  surface  of  the  old,  and 
in  the  Haversian  canals  of  the  compact  tissue. 

Necrosis  is  not  rare. 

Acute  osteomyelitis. — Acute  osteomyelitis 
forms  part  of  a  general  inflammation  of  the  soft 
tissue  of  bone ;  or  it  is  set  up  by  destructive  disease 
of  a  contiguous  joint,  or  it  arises  as  a  primary  affec- 
tion. 

As  the  exudation  is  pent  up  under  high  pressure, 
and  there  is  no  possibility  of  an  early  spontaneous 
evacuation,  necrosis  is  almost  certain  to  follow. 

The  patient  often  dies  poisoned  by  the  septic 
matter  before  the  sequestrum  is  loosened. 

The  inflammation  may  lapse  into  a  chronic  state, 
an  exit  for  the  pus  being  provided  by  operation,  or 
the  opening  up  of  channels  in  the  bone  by  rarefying 
ostitis. 

Osteophlebitis,  or  osteo-thrombosis  is  a 
concomitant  of  osteomyelitis,  whether  pathological 
or  traumatic.  The  coagula  are  very  liable  to  dis- 
integrate and  break  up  into  emboli,  for  they  are 
steeped  in  a  highly  irritative  or  infective  fluid. 
Moreover,  as  the  veins  lie  in  rigid  canals,  to  the 
walls  of  which  they  are  adlierent,  thej  are  unable  to 
collapse  when  divided  or  torn. 


228 


CHAPTER   XXXIY. 

OSSEOUS    LESIONS    IN    CONGENITAL    SYPHILIS. 

Affections  of  the  osseous  system  in  congenital 
syphilis  stand  midway  between  those  of  the  skin  and 
the  viscera  in  order  of  frequency. 

Our  knowledge  of  the  subject  has  been  mainly 
derived  from  the  researches  of  Wegner  and  Parrot 
abroad,  and  Drs.  Barlow  and  Lees  in  this  country.* 

In  one  way  or  another,  every  part  of  the  skeleton 
is  liable  to  be  diseased,  but  the  points  of  greatest 
interest  are  centred  in  the  long  hones,  the  cranium, 
and  the  teeth. 

Cranial  bones. — The  lesions  here  are  of  two 
kinds  (1)  atrophic;  (2)  osteophytic. 

Localised  wasting  of  the  cranial  vertex  is  met 
with  in  the  parts  most  subject  to  pressure  from  de- 
cubitus, and  it  is  all  the  more  marked  if  at  the  same 
time  there  is  an  increase  of  fluid  in  the  cerebral 
ventricles.  The  usual  situation  is  the  parietal  bone 
behind  the  eminence,  but  it  has  been  observed  in  the 
occipital  and  squamous  bones.  The  bone  is  gradually 
absorbed  until  nothing  is  left  but  a  thin  plate,  or 
membrane,  of  parchment-like  consistence,  wliich  readily 
yields  under  the  pressure  of  the  finger.  The  same 
condition  occurs  in  rickets,  but  not  so  frequently  as 
in  congenital  syphilis.  The  absorption  leads  to  a  well- 
marked  depression  of  the  inner  surface  of  the  bone. 

It  is  a  case  of  atrophy  from  continued  pressure 
acting  upon  a  tissue  preternaturally  soft  and  weak. 
The  process    is  designated    craniotabes.     It  is  found 

*  An  admirable  account  of  the  lesions  is  contained  in  the 
Transactions  of  the  Pathological  Society,  vol.  xxx. 


Chap.  XXXIV.] 


Parrot's  Nodes. 


229 


in  very  young  infants.  M.  Parrot  has  described 
another  form  of  atrophy,  which  he  terms  "gelatino- 
form."  As  the  name  denotes,  it  consists  of  conversion 
of  the  bone  into  a  soft  material.  It  begins  beneath 
the  pericranium,  but  rarely  spreads  as  far  as  the  dura 
mater.      It  cannot  be  diagnosed  during  life. 

Parrot's  osteophytes  or  nodes  are  subperiosteal  de- 
posits of  new  bone  (Fig.  30).  They  are  situated  upon 
the  four  processes  that  bound  the  anterior  fontanelle,  to 
which  they  give  a  natiform  appearance.  Other  de- 
posits are  usually  found  upon  the  parietal  bones,  and 
chiefly  along  the  co- 
ronal and  saojittal 
sutures.  It  will  be 
seen  that  they  affect 
neither  the  frontal 
nor  jDarietal  eminen- 
ces, nor  the  sites  of 
craniotabes,  or  only 
in  very  severe  cases. 
The  new  bone  is 
very  vascular  and 
porous  when  first 
formed.  It  consists 
of  a  series  of  trabe- 
culse,  between  which 
are  spaces  filled  with 
a  pulpy  marrow. 
The  vessels   run  at 

rio-ht    angles    to    the    Fig.  30.-View  of  Outer  Surface  of  Cranium 
surface  of  the  skull.  afEected  with.  Congenital  Syphilis. 

Tbp  "KnmT-  f»T>Ti  «  and  6  point  respectively  to  a  frontal  and  parietal 
j-Aic  KJKixiy  ciiii-  nodeorhoss.  These  nodes  are  composed  of  bone 
of  a  coarser  texture  than  that  which  bridges  over 
the  anterior  fontanelle,  d;  c,  fronto-parieral 
suture  ;  throughout  the  greater  part  of  its  extent 
It  is  obliterated  by  ossiflc  deposit  ;  e,  i)arietal 
eruinence.  The  natiform  nodes  bounding  the 
anterior  fontanelle  are  somewhat  too  sharply 
defined  in  the  diacrara.  The  preparation  is  in 
the  Museum  of  the  Hospital  for  Sick  Children, 
Gre.-it  Ovmond  Street,  and  is  represented  here  by 
permission  of  Dr.  D.  Lees. 


nences  may  attain  a 
thickness  of  more 
than  half  an  inch  at 
their  centres. 

The     f  r  o  n  t  o  - 


230  Surgical  Pathology.      [Chap.  xxxiv. 

parietal  sutures  are  sometimes  obliterated  by  an 
extension  of  ossification  from  one  bone  to  the  other. 

These  osteophytes  are  quite  characteristic  of  con- 
genital syphilis.  In  the  majority  of  cases  they  form 
between  the  sixth  and  twelfth  month.  Ulcerating 
nodes,  though  common  in  acquired  syphilis,  are  ex- 
cessively rare  in  congenital  ;  Barlow  records  one  such 
case. 

The  long-  bones. — As  in  the  cranium,  the 
disease  shows  itself  in  two  forms,  atrophic  and 
productive. 

The  atrophic  changes  are  seen  in  the  growing  layer 
of  the  tissue  on  the  diaphysial  side  of  the  epiphysial 
cartilage.  It  is  sometimes  described  as  an  osteo- 
chondritis, but  it  appears  to  consist  essentially  of  a 
deviation  from  normal  development.  The  inflammatory 
changes  are  secondary,  and  dependent  upon  injury. 

There  are  two  distinct  changes  :  (1)  an  excessive 
deposit  of  lime-salts  in  the  cartilage  matrix  and 
capsules,  and  imprisonment  of  the  cartilage  cells.  This, 
whilst  it  increases  the  brittleness  of  the  part,  puts  a 
stop  to  the  ossification  ;  (2)  an  overgrowth  of  gela- 
tinous medulla  or  spongeoid  tissue  in  the  ossiform 
layer  (that  next  the  cartilage) ;  this  absorbs  the  pre- 
formed bone,  and  may  end  in  complete  separation  of 
the  epiphysis.  The  fragility  due  to  calcification,  and 
the  softening  caused  by  "  gelatiniform  atrophy  "  render 
the  bone  liable  to  bend  or  break  on  the  slightest 
injury.  Then  the  irritation  caused  by  the  injury  sets 
up  a  veritable  inflammation,  which  may  end,  though 
rarely,  in  suppuration.  If  the  child  survives  the 
cachexia  of  the  disease,  the  epiphysial  lesion  subsides, 
and  ossification  goes  on  in  the  normal  way. 

When  the  morbid  process  is  in  progress  the  limb 
hangs  helj)lessly  from  the  trunk.  Parrot  calls  this 
condition  "syphilitic  pseudo-paralysis,"  to  distinguish 
it   from    essential    or  infantile  paralysis,   of  nervous 


Chap.  XXXIV.]         Syphilitic  Teeth.  231 

origin,  in  which  there  is  actual  powerlessness  of  the 
muscles. 

Osteophytes  form,  as  a  rule,  after  the  sixth  month  of 
extra-uterine  life.  The  bones  most  frequently  affected 
are  the  tibia  and  humerus.  I  have  seen  symmetrical 
osteophytes  on  the  upper  ends  of  the  ulnse.  They 
consist  of  highly  vascular  spongy  bone,  the  trabeculse 
of  which  stand  perpendicularly  to  the  axis  of  the 
limb.  They  are  usually  constructed  of  a  number  of 
superposed  lamellae,  united  by  narrow  bars  or  columns, 
imbedded  in  a  soft  medulla.  Sometimes  the  osteo- 
phytes are  quite  soft,  and  are  made  up  of  fibro- 
vascular  tissue.  Between  the  two  forms  there  is 
every  gradation.  The  tibial,  ulnar,  and  radial 
osteophytes  are  mostly  situated  at  the  upper  epiphyses; 
the  humeral  at  the  lower.  In  the  scapula  they  are 
found  in  the  spinous  fossse  ;  in  the  hip,  the  external 
iliac  fossa. 

Maxillae  and  teeth. — The  characters  of  the 
teeth  described  by  Mr.  J.  Hutchinson  consist  of  mal- 
formation and  defective  structure.  Those  most 
commonly  affected  are  the  upper  permanent  central 
incisors.  Instead  of  the  borders  of  the  cutting  edges 
being  in  contact,  they  are  separated  by  a  gap.  There 
is  a  central  indentation  or  notch  in  the  place  that 
should  be  occupied  by  the  middle  tubercle.  The  lower 
incisors  are  sometimes  pegged,  and  the  canines  (upper 
and  lower)  more  pointed  than  natural.  The  inilk  teeth 
are  subject  to  early  decay  and  premature  shedding. 
The  date  of  eruption  is  not  deferred,  as  it  is  in  rickets 
(Eustace  Smith).  Mr.  Hutchinson  attributes  the  mal- 
development  to  specific  stomatitis,  which  affects  the 
gums,  periosteum,  and  bone  in  infancy.  The  above- 
described  lesions,  which  are  incidental  to  the  early 
stages  of  congenital  syphilis,  are  sometimes  associated 
with  falling  in  of  the  bridge  of  the  nose  from  defective 
growth  of  the  nasal  bones,  the  result  of  inliammatory 


232  Surgical  Pathology.       [Chap.  xxxv. 

changes.  There  may  also  be  rarefaction  of  the 
diaphyses  of  the  long  bones  coincidental  with  atrophy 
and  enlargement  of  the  epiphyses. 

In  the  tertiary  period  serious  lesions  are  met  with; 
to  wit,  caries  and  necrosis  of  the  nasal  and  other 
bones,  hypertrophy  of  the  long  bones  from  diffuse 
interstitial  osteoplastic  ostitis,  and  localised  thicken- 
ings from  osteo-periostitis  (nodes) 


CHAPTER  XXXV. 

NECROSIS. 

Necrosis  happens  when  the  circulation  in  a  portion 
of  bone  is  permanently  arrested,  from  injury  or 
disease.  In  the  former  case,  if  many  vessels  be 
ruptured  by  violent  concussion  or  fracture,  the 
current  through  them  is  arrested  by  thrombosis  in 
the  torn  ends,  and  by  the  pressure  of  extravasated 
blood.  In  fracture,  too,  with  considerable  displace- 
ment of  the  fragments,  and  especially  if  there  be 
much  splintering,  portions  may  be  entirely  denuded  of 
periosteum.  Should  the  bone  survive  these  accidents, 
it  has  to  cope  with  the  obstruction  from  inflammatory 
exudation,  so  that  it  is  not  surprising  that  necrosis  is 
often  of  traumatic  origin. 

Syphilitic  ostitis  leads  to  necrosis,  either  imme- 
diately, by  occlusion  of  the  vessels  from  the  pressure 
of  the  effusion,  or  more  remotely  through  the 
Haversian  canals  becoming  narrowed  by  deposit  of 
new  bone  within  them,  until  at  last  they  become 
entirely,  or  all  but,  obliterated,  so  that  the  blood 
supply  is  too  scanty  to  support  the  life  of  the  affected 
part. 


Chap.  XXX V.  ]      Super  ficia  l  Necr  osis.  233 

When  discussing  the  subject  of  abscesses  in 
carious  epiphyses  it  will  be  shown  that  they  often 
contain  sequestra  of  considerable  size,  the  result  of  acute 
ostitis,  or  of  caseation  of  tracts  of  granulation  tissue, 
with  thrombosis  of  the  vessels.  According  to  Cornil 
and  Ranvier,  caries  is  essentially  due  to  primary  fatty 
degeneration  of  the  bone  corpuscles,  which  entails  a 
death  of  the  osseous  laminse  within  their  territories. 
They  assert  that  these  laminse  then  act  as  irritants, 
and  set  up  a  rarefying  ostitis  which  gradually  absorbs 
the  bone,  accompanied  or  not  by  further  necrosis. 
Lastly,  whatever  the  cause  of  arrested  circulation,  bone 
succumbs  with  other  tissues  in  a  general  gangrene. 

Superficial  necrosis,  exfoliation. — A  good 
example  of  this  is  seen  in  injuries  to  the  cranial  vertex, 
where  the  pericranium  is  destroyed,  with  probably  some 
slight  extravasation  into  the  diploe  and  external  plate. 
Unless  the  dura  mater  be  detached,  the  inner  table 
escapes  death,  for  it  is  plentifully  supplied  by  the 
meningeal  vessels.  Inflammatory  effusion  completes 
the  stasis  in  those  parts  already  crippled,  but  it  must 
not  be  supposed  that  the  inflammation  is  limited  to 
the  part  that  dies,  for  it  gradually  subsides  into  the 
healthy  bone.  The  layer  that  is  continuous  with 
the  necrosed  portion  becomes  rarefied  by  absorption, 
the  granulations  thrusting  their  buds  through  the 
walls  of  contiguous  Haversian  canals,  so  that  the  latter 
open  into  one  another.  Finally  the  attenuated  osseous 
laminae  disappear,  and  the  dead  part  is  cast  off.  These 
changes  take  place  chiefly  in  the  tissue  that  has  re- 
tained its  vitality,  but  that  the  inflammatory  new 
formation  is  able  to  absorb  dead  bone  is  proved  by  the 
erosion  of  ivory  pegs  employed  in  ununited  fractures. 
Moreover,  it  is  not  rare  to  find  perforations  of  thin 
superficial  sequestra  by  pink  granulations,  a  welcome 
sign  to  the  surgeons,  for  it  tells  at  once  of  the  shallow 
depth  of  the  necrosis.     It  is  this  riddling  of  the  bone 


234  Surgical  Pathology.        [Chap.  xxxv. 

that  causes  it  to  crumble  down  during  detachment. 
The  source  of  irritation  being  removed,  the  layer  of 
florid  embryonic  tissue  that  covers  the  surface  begins 
to  organise.  The  new  bone  is  deposited  around  the 
vessels.  It  acquires  considerable  density.  A  new 
periosteum  is  constructed  from  the  outer  layer  of 
granulations. 

The  exact  method  of  absorption  of  bone  is  not 
known.  Virchow  believes  that  cells  (osteoclasts), 
derived  from  proliferation  of  bone  corpuscles,  are  the 
active  agents.  E/indfleisch  suggests  that  the  blood  in 
the  congested  vessels  containing  an  excess  of  carbonic 
acid  may  dissolve  the  lime  salts,  forming  an  acid 
carbonate.  Others  suppose  that  lactic  acid  is  de- 
veloped, and  that  this,  combining  with  the  earthy 
base,  forms  soluble  calcic  sarco-lactate.  The  two 
latter  hypotheses  are  improbable,  for  bone  exposed  to 
the  action  of  pus  for  months  or  years  loses  little  or 
none  of  its  substance,  and  it  retains  its  smoothness  of 
surface  from  the  time  when  it  becomes  sequestrated. 
Whilst  denying  the  origin  of  the  bone-destroying  cells 
ascribed  by  Yirchow,  I  believe  his  view  of  absorption 
by  the  vital  action  of  living  matter  to  be  quite  rational. 
An  exfoliated  lamina  of  bone  is  smooth  on  the  outer 
surface,  where  it  undergoes  no  change  of  structure  in 
the  osseous  framework,  but  it  looks  worm-eaten  on 
the  under  surface,  the  indentations  having  been 
formed  and  occupied  by  vascular  granulations.  If 
vertical  sections  of  artificially-softened  bone  be  made 
during  the  process  of  separation  of  a  sequestrum,  it 
will  be  seen  that  the  Haversian  canals  of  the  necrosed 
portion  are  empty,  or  contain  nothing  but  the  debris 
of  disintegrated  marrow,  whilst  the  spaces  of  the 
living  bone  are  filled  with  embryonic  cells  and  blood- 
vessels in  a  state  of  active  proliferation.  Picro- 
carmine  stains  the  osseous  trabeculse  yellow,  and  the 
granulation  tissue  red,  and  shows  a  beautiful  layer  of 


Chap.  XXXV.] 


A^ECROSIS. 


235 


S 3. 


-—b 


demarcation  which  ends  abruptly,  and  is  most  intense 
in  colour  next  the  dead  bone,  but  gradually  fades 
away  into  the  living.  The  adjacent  periosteum  is 
infiltrated  with  indifferent  cells,  especially  in  the 
deeper  part. 

Pus  escapes  from  the  vessels  of  the  granulations  at 
the  margin,  and  also  beneath  the  sequestrum  when 
this  is  loose. 

Necrosis  of  an  amputation  stump.  —  Am- 
putation through  a  long  bone  is  a  good  example  of 
compound  fracture,  and 
the  wonder  is  that 
necrosis  does  not  more 
frequently  result,  for 
the  vessels  of  the  me- 
dulla and  periosteum 
are  severed,  and  their 
ends  compressed  by  ex- 
travasated  blood,  and 
necessarily  plugged  by 
clots.  At  the  same  time, 
the  vitality  of  the  bone 
may  be  impaired  from 
disuse  or  existing  in- 
flammation,  both  of 
which  conditions  readily 
allow  of  detachment  of 
the  periosteum  if  trac- 
tion be  made  upon  the 
flaps. 

Without  exception, 
the  injury  inflicted  by 
the  operation  sets  up 
an  inflammatory  reac- 
tion ;  the  medulla  of  the 
central  canal,  that  contained  in  the  substance  of  the 
bone,  and  the  periosteum,  all  show  acute  hypersemia 


— c 


•a 


Fig.  31.—  ISTecT'osis  of  Femtir  after 
Amputation  of  Tliigh. 
a,  dead  bone  more  extensive  on  medullary 
aspect ;  c,  new  bone  deposited  from 
periosteum,  adherent  to  h,  the  living  por- 
tion of  the  shaft,  hut  free  from  the 
necrosed  portion,  a;  d,  medulla  deeply 
congested  andhsemorrhagic  ;  e,  the  same, 
decolorised  and  purulent,  in  process  of 
disintegration. 


236  Surgical  Pathology.       [chap.  xxxv. 

and  exudation,  and  return  to  the  embryonic  state. 
This  is  followed  by  a  rarefying  ostitis.  In  ordinary 
cases  the  inflammation  does  not  go  beyond  this,  but, 
subsiding,  ends  in  a  condensation  from  deposit  of 
new  bone,  which  greatly  narrows  the  vascular  channels, 
and  fills  the  open  end  of  the  medullary  canal.  Upon 
the  completion  of  these  changes,  atrophy  from  partial 
loss  of  function  sets  in,  and  the  end  of  the  bone  there- 
by becomes  conical. 

In  the  event  of  necrosis,  one  or  more  of  the 
hindrances  to  the  circulation  is  increased ;  thus,  the 
periosteum  is  stripped  off  to  such  an  extent  that  the 
bone  cannot  recover  itself,  or  a  central  osteomyelitis 
destroys  the  medulla  (Fig,  31). 

The  sequestriun. — Stasis  from  the  latter  cause 
usually  exceeds  that  from  the  former,  and  so  the 
necrosis  is  more  extensive  on  the  inner  aspect,  account- 
ing for  the  sequestrum  appearing  in  the  shape  of  a 
truncated  cone,  whose  outer  surface  is  excavated  into 
shallow  pits  and  grooves  by  the  granulation  tissue 
during  the  process  of  separation.  Whilst  the  rarefy- 
ing ostitis  is  going  on  in  the  substance  of  the  bone,  in 
order  to  set  free  the  dead  portion,  ossification  is  pro- 
gressing in  and  beneath  the  periosteum,  so  that  the 
outer  surface  becomes  incrusted  with  soft  spongy  bone. 
"When  once  the  sequestrum  is  removed,  and  it  usually 
requires  an  operation  to  effect  this,  the  subsequent 
changes  differ  in  no  way  from  those  occurring  in  the 
healing  of  a  stump  by  granulation  without  necrosis. 

These  sequestra  vary  much  in  size.  They  may  be 
many  inches  in  length,  and  of  great  thickness,  or  so 
small  as  to  break  in  pieces  during  attempts  at  removal. 
Their  lower  ends  are  sometimes  smooth  on  the  outer 
surface  for  a  short  distance,  showilng  that  the 
periosteum  was  destroyed  to  a  like  extent,  and  that 
the  granulations  left  untouched  the  denuded  bone. 
In  other  cases  the  outer  surface  is  smooth,  and  the 


Chap.  XXXV.]  Central  Necrosis.  237 

inner  rough  throughout,  the  loss  of  vitality  being  more 
of  periosteal  than  medullary  origin;  it  is,  in  fact, 
superficial,  and  not  central  necrosis. 

Whatever  the  variety,  the  general  shape  is  quite 
characteristic,  ending  abruptly  below  ^vith  a  sawn 
surface,  tapering  above.  The  cavities  from  which 
they  are  removed  are  never  bare,  but  are  lined  by  a 
soft,  vascular,  pyogenic  membrane,  which,  increasing, 
soon  fills  up  the  spaces  and  ossifies. 

Central  or  internal  necrosis  may  ensue  from 
osteomyelitis,  without  a  previous  loss  of  continuity  in 
the  bone,  the  osteomyelitis  being  either  primary,  or 
forming  a  part  of  a  more  widespread  lesion  of 
periosteum  and  medulla.  In  the  former  case  it 
begins  (1)  as  an  acute  suppurative  inflammation  in 
the  central  canal,  when  it  is  often  fatal  before  the 
sequestrum  is  loose ;  or  (2)  as  an  ostitis  of  the  can- 
cellous tissue  of  an  epiphysis,  which  spreads  to  the 
interior  of  the  shaft.  In  young  people  the  epiphysial 
cartilage  is  perforated  by  the  advancing  disease. 

In  this  variety  the  march  of  events  is  less  rapid, 
so  that  there  is  time  for  the  inflammation  to  subside, 
and  the  dead  bone  to  be  thrown  ofi"  into  the  medullary 
canal.  Relief  is  given  to  the  tension  by  the  bursting 
of  an  abscess  which  communicates  directly  with  the 
exterior,  or  in  a  more  roundabout  way  by  the  con- 
tiguous joint. 

Scrofula  is  often  at  the  root  of  the  evil,  so  it  is 
not  surprising  that  caries  and  joint  disease  complicate 
this  form  of  necrosis.  The  medullary  canal  becomes 
flUed  with  granulation  tissue  and  pus,  in  which  the 
sequestrum  is  imbedded. 

Outlets  to  the  purulent  exudation  are  made  here 
and  there  by  absorption  of  the  osseous  trabeculse, 
where  the  tension  is  greater  than  elsewhere.  These 
outlets,  which  in  the  case  of  bone  are  called  cloacce, 
correspond  to  sinuses  in  the  soft  tissues. 


238 


Surgical  Pathology,       [Chap.  xxxv. 


Central  can  always 
be  told  from  total 
necrosis  by  the  se- 
questrum appearing 
rough  and  worm- 
eaten  in  the  former, 
smooth  in  the  latter. 

The  encasing  shell 
of  bone  is  entirely  of 
new  formation  in 
total  necrosis,  where- 
as in  central  necrosis 
it  is  composed  of  the 
outer  portion  of  the 
original  shaft,  thick- 
ened by  external  de- 
posit. 

Sequestrotomy  is 
necessary  for  the 
liberation  of  the  se- 
questrum, which,  so 
long  as  it  is  retained, 
keeps  up  suppura- 
tion, a  cause  of  hectic 
fever,  phthisis,  and 
lardaceous  disease. 
Nature,  unaided, 
seems  content  with 
lowering  the  tension 
to  the  level  of  chronic 
inflammation. 

Acute  total 
It 


necrosis. 


is 


Fig.  32. — Necrosis  of  the  Femur. 
The  sequestrum,  a,  liad  been  locked  up  f  oi-  eight  years,  and  had  by  its  weight  and 
friction  bored  a  passage  through  the  epiphysis  into  the  knee-joint  (atrophy 
from  continuous  pressure) ;  the  articular  cartilages  are  but  little  affected  ; 
h,  cloaca  through  which  the  pus  escaped  from  the  sequestrum  cavity,  which 
in  the  fresh  state  was  lined  with  granulation  tissue  ;  c,  new  hone  ;  d,  osseous 
deposit  that  bas  filled  in  the  medullary  canal;  e,  patella ;  behind  this,  the 
tibia  and  fibula.    (Half  natural  size. ) 


Chap.  XXXV.]  Acute  Necrosis.  239 

impossible,  clinically,  to  draw  a  hard  and  fast  line 
between  so-termed  partial  and  total  necrosis  ;  indeed, 
such  a  division  is  unnatural,  for  many  of  the  cases  com- 
plete in  the  pathology  of  the  disease  in  question  fall 
short  of  death  of  an  entire  diaphysis.  The  symptoms 
and  morbid  signs  are,  notwithstanding,  so  marked  as  to 
justify  a  special  description.  Stripped  of  its  details, 
the  history  runs  thus  :  An  often  unaccountable  onset, 
rapid  progress,  tendency  to  end  in  a  fatal  pyaemia, 
with  secondary  lesions,  and  liability  to  select  the 
periods  of  childhood  and  youth.  It  is  an  acute  sup- 
purative or  phlegmonous  inflammation  of  the  growing 
part  of  bone,  at  one  time  limited  to  a  periostitis  and 
superficial  ostitis,  at  another  involving  the  destruction 
of  the  epiphysial  cartilage,  and  even  the  entire 
medulla. 

The  epiphyses  themselves,  as  a  rule,  escape,  or,  at 
any  rate,  are  not  affected  past  recovery,  although  the 
inflammation  may  spread  through  them  to  the  con- 
tiguous joints. 

Causes. — Injury,  acute  specific  diseases,  such  as 
scarlet  fever  and  measles,  and  exposure  to  wet  and 
cold,  have  been  assigned  as  the  causes,  but  at  most 
they  can  only  be  considered  as  exciting  agents.  There 
must  be  some  underlying  disposition  on  the  part  of 
the  tissues  attacked. 

Diagnosis. — The  severity  of  the  constitutional 
symptoms  and  the  obscurity  of  origin  account  for  many 
of  the  mistakes  in  diagnosis.  Children  are  sometimes 
brought  to  hospital  because  a  supposed  erysipelas  or 
acute  rheumatism  has  not  run  an  expected  course,  the 
first  idea  of  the  real  state  of  things  being  aroused 
perhaps  by  the  evidence  of  fluctuation  over  a  bone ; 
and  even  this  may  be  overlooked,  the  enigma  being 
solved  on  the  post-mortem  table.  A  previously  healthy 
girl  of  fourteen  was  treated  for  rheumatism,  but 
getting  rapidly   worse,   with   high  fever,   wide-spread 


240  Surgical  Pathology.       [Chap.  xxxv. 

muscular  spasm,  and  delirium,  was  taken  to  the  medical 
ward  of  a  hospital,  where  at  first  the  possibility  of 
cerebro-spinal  meningitis  was  entertained,  there  being 
no  apparent  sign  by  which  to  localise  the  disease. 
After  death,  the  right  clavicle  was  found  lying  in  a 
bed  of  pus,  and  the  lungs  riddled  with  small  metastatic 
abscesses.  Subject  to  these  important  exceptions,  the 
local  signs  can  scarcely  be  mistaken.  The  tensive 
pain  and  exquisite  tenderness,  the  redness  of  the 
skin,  and  the  fluctuation  or  bogginess  of  the  part, 
tell  their  own  tale. 

Dissection. — Tlie  skin  and  cellular  tissue  appear 
congested  and  highly  cedematous,  the  periosteum  is 
detached  to  a  variable  extent,  and  the  bone  over  the 
same  area  is  bathed  in  pus.  The  epiphyses  may  be 
found  loose,  and  the  joints  healthy  or  inflamed;  in 
the  latter  case,  either  by  the  spreading  of  the  local 
disease  or  by  metastatic  infection. 

If  the  bone  be  sawn  vertically,  the  central  medulla 
will  present  a  deep  red  colour  from  congestion,  with 
here  and  there  patches  of  capillary  extravasation, 
interspersed,  perhaps,  with  collections  of  pus,  which 
are  generally  situated  at  the  periphery,  the  canal  for 
the  nutrient  artery  forming  a  purulent  tract,  that 
connects  the  superficial  with  the  central  suppuration. 

The  compact  and  cancellous  tissue  presents  a 
mottled  appearance  in  place  of  the  difiused  pinkish- 
white  tint  of  healthy  bone,  for  the  spaces  are  occupied 
by  purulent  exudation  and  dilated  vessels,  which  are 
filled  with  dark  deoxydised  clots.  Later  on,  of  course, 
the  contents  of  these  spaces  disintegrate,  and  leave  the 
bare  osseous  framework  v/hite  or  yellowish-white,  and 
lustreless. 

Venous  thrombi  within  and  without  the  bone  may 
be  softened,  and  ready  to  develop  a  septic  embolism. 

If  any  part  of  the  bone  escape  death,  it  be- 
comes encrusted  with  ossific  deposit,  which  forms  an 


Chap.  XXXV.]  ACUTE  Necrosis.  241 

appreciable  layer  within  ten  days,  provided  the  tension 
has  been  relieved  by  incision.  Should  the  necrosis  not 
be  total,  it  is  the  deeper  portion  of  the  bone  that 
survives,  for  this  receives  its  vascular  supply  more 
directly  from  the  large  vessels,  the  higher  arterial 
pressure  tending  to  check  blood  stasis ;  and  being 
deeply  seated,  it  is  better  supported  and  less  exposed 
to  injury. 

The  tibia  is  affected  more  often  than  any  other  bone. 

Complicated  l>y  pysemia. — In  this  disease  the 
blood  becomes  charged  with  infective  matter,  but  how 
it  originates  is  uncertain  ;  not  necessarily  by  contagion 
through  a  wound,  for,  as  before  said,  all  the  signs  of 
virulent  pysemia  may  arise  without  the  local  abscess 
having  been  opened.  The  theory  of  autogenetic 
origin  is  not  borne  out  by  facts,  and  this  being 
granted,  we  are  driven  to  suppose  that  whatever  the 
materies  morbi  may  be,  it  is  introduced  by  the  skin,  or, 
more  likely,  by  the  mucous  membranes.  The  analogy 
furnished  by  the  acute  specific  diseases  supports  this 
view.  At  the  same  time,  there  can  be  no  doubt  but 
that  it  finds  a  suitable  nidus  for  development 
and  reproduction  in  the  products  of  the  local  in- 
flammation. 

The  living  structures  strive  to  get  rid  of  matter 
obnoxious  to  themselves,  and  do  their  best  to  destroy 
any  organisms  that  infest  the  blood  and  tissues ;  but 
they  may  be  overpowered  by  the  intensity  of  the 
initial  infection,  or  succumb  to  the  continued  absorp- 
tion under  high  pressure  from  the  seat  of  primary 
suppuration. 

Early  and  free  incisions,  by  lowering  the  tension, 
check  the  progress  of  the  inflammation,  and  diminish 
the  risk  of  blood-poisoning  by  providing  for  the  escape 
of  the  exudation. 

Repair. — The  loss  of  the  whole  or  greater  portion 
of  a  shaft  is  replaced  by  new  bone,  deposited  from 

Q 


242 


Surgical  Pathology 


[Chap.  XXXV. 


\-l 


a 


any  of  the  original  j)eriosteum 
that  may  have  remained,  and 
from  the  fibrous  structures 
around;  nor  is  it  necessary,  as 
was  formerly  supposed,  that  the 
necrosed  bone  should 
be  left  for  a  long 
time  to  act  as  a 
stimulus  to  ossifica- 
tion, recent  practice 
having  shown  that 
early  "  subperiosteal 
I  I  iiii  resections  "  are  suc- 
cessful. I  have  seen 
complete  restoration 
of  the  diaphysis  of  a 
tibia  that  was  re- 
moved on  the  tenth 
day  from  the  onset 
of  the  disease  (Mr. 
W.  Pye'scase).*  The 
younger  the  patient 
the  greater  is  the 
developmental  acti- 
vity, and  the  more 
rapid  the  reconstruc- 
tion. 

If  the  epiphysial 


ToteTNlo^olis   cartilages  have  been 
oiailS   clestroyed 

the  result  of 


acute  Syphi- 
litic Ostitis 
and  Peri- 
ostitis. 

The  .sequestnmi 
separated  natu- 
Mlly,  a.s  shown 
hy  the  irregular 
worm-eaten  ap- 
pearance of  its 
ends.  (One- 

third  natural 
size.) 


the  new 
shaft  will  not  attain 
to  the  length  it  other- 
wise would  have  done. 

Phosphorus 
necrosis  of  the 
jaws— The  disease 
is  less  common  than 

*  Lanret,  vol.  ii.,  1879,  p.  654. 


— ShoTvs  complete  Re- 
storation of  the  Shaft  of  the 
Bone  after  original  one  had 
been  destroyed  by  Necrosis. 
From  the  same  subject  as  A. 
a,  Caries  of  the  new  bone ;  6,  hridee 
of  bone  un  itiug  th  e  tibia  with  tiie 
fibula.  (One-lhird  natural  size. 
yide\\.  218.) 


Chap.  XXXV.]  Quiet  Necrosis.  243 

formerly ;  for  red  amorphous  phosphorus  is  used 
instead  of  the  yellow  variety,  and  workers  in  phos- 
phorus look  more  after  the  state  of  their  teeth.  It 
is  caused  by  the  acid  fumes  of  phosphorus  (probably 
phosphorus  acid)  acting  upon  exposed  or  unhealthy 
bone  in  the  vicinity  of  carious  teeth.  The  disease 
may  begin  as  an  acute  osteo-periostitis,  which  rapidly 
ends  in  necrosis  ;  or  it  may  be  preceded  by  an  osteo- 
plastic inflammation.  This  depends  on  the  intensity 
of  the  cause,  and  the  extent  of  caries  of  the  teeth  and 
exposure  of  the  alveolar  process  of  the  jaw.  The 
final  result  is  death  of  the  whole,  or  a  large  portion, 
of  the  jaw.  An  exuberance  of  spongy  vascular  bone 
is  deposited  around  the  sequestrum,  which  often  takes 
a  long  time  to  separate.  Sequestrotomy  has  been 
known  to  cause  severe  bleeding;  in  one  case  the 
carotid  had  to  be  tied  to  arrest  it. 

"  Quiet  necrosis." — Sir  J.  Paget  has  desciibed  a 
form  of  necrosis  in  which  the  death  of  the  bone  and 
separation  of  the  sequestrum  take  place  without 
manifest  signs  of  inflammation.  In  fact,  the  patient 
may  be  quite  ignorant  of  there  being  anything  wrong. 
This  "quiet  necrosis"  is  sometimes  internal;  more 
often  superficial.  The  sequestra  lie  in  cavities  lined 
by  granulation  tissue,  but  they  excite  so  little  irrita- 
tion that  no  external  openings  are  formed.  The 
periosteum  is  "thickened,  tough,  and  little  vascular." 
A  similar  process  is  occasionally  observed  in  connec- 
tion with  articular  cartilage  ;  slight  injury  appears  to 
be  the  exciting  cause. 


244 


CHAPTER   XXXYI. 

BONE   ABSCESS. 

Bone  abscess  is  either  tlie  result  of  an  injury,  or 
constitutional  disease,  such  as  struma  or  syphilis. 
The  favourite  locality  is  the  end  of  a  long  bone  ;  but 
it  may  be  found  wherever  there  is  a  wide  tract  of 
cancellous  tissue,  as  in  the  tarsal  bones  and  the  verte- 
brae. Commencing  in  a  rarefying  ostitis,  a  cavity  is 
formed  by  the  gradual  absorption  of  the  bony  trabe- 
culse  by  granulation  tissue ;  this  granulation  tissue,  in 
its  turn  degenerating,  mingles  its  debris  with  more 
recent  exudation  of  pus,  and  the  abscess  is  completed. 
At  first  its  walls  are  composed  of  soft  carious  bone, 
which,  if  the  inflammation  spreads,  gradually  becomes 
disintegrated,  the  cavity  enlarging  at  its  expense. 

But  here  the  destructive  process  may  end,  and  an 
organising  one  begin.  New  bone  is  deposited  around 
the  vessels  of  the  granulation  tissue,  and  this  goes  on 
until  a  zone  of  hard  sclerosed  bone  has  replaced  that 
previously  softened. 

The  layer  of  granulation  tissue  immediately  lining 
the  cavity  is  converted  into  fibrous  tissue  (a  kind  of  end- 
osteum)  ;  all  formed  elements  found  in  the  contents  of 
the  abscess  break  down  from  fatty  degeneration,  and 
only  a  serous  or  seropurulent  fluid  remains.  In  some 
cases  it  would  appear  that  the  granulation  tissue 
having  completely  absorbed  the  bone  for  a  consider- 
able distance,  does  not  liquefy,  but  undergoes  caseation, 
the  bone  around  becoming  condensed,  as  described 
above. 

More  frequent  than  either  of  the  above  modes  of 
termination  is  a  progressive  absorption  of  the  bone, 


Chap.  XXXVII.]  Mo  L  LI  TIES    OSSIUM.  245 

until   the    abscess  opens  by  a  narrow  orifice,  either 
upon  the  surface,  or  into  the  contiguous  joint,  or  both. 

At  the  outset  the  obstruction  to  the  circulation  in 
the  bone  may  be  so  great  that  a  portion  becomes 
necrosed,  and  is  afterwards  set  free  in  the  cavity 
formed  by  the  more  gradual  destruction  (rarefying 
ostitis). 

Bone  abscess  forms  a  conspicuous  feature  in  the 
pathology  of  many  cases  of  strumous  disease  of  joints. 

Care  should  be  taken  in  probing  them  through  a 
sinus  opening  externally,  as  they  are  often  bounded 
next  the  joint  by  the  articular  cartilage  alone,  and 
this  might  be  inadvertently  detached. 

When  confined  to  the  interior  of  the  bone,  and 
very  chronic,  the  only  symptom  perhaps  is  localised 
aching,  and  the  chief  sign  a  fixed  spot  of  tenderness 
to  touch. 

Once  opened,  they  rarely  close  spontaneously,  or, , 
if  so,  only  for  a  time.  The  tension  being  relieved  by 
discharge,  the  sinus  leading  to  the  abscess  cavity 
shrinks  until  the  re-accumulation  of  pus  again  raises 
the  pressure  and  renders  the  orifice  patent.  Tre- 
phining, by  giving  a  free  exit,  removes  the  tension 
which  is  the  chief  local  cause  of  non-obliteration  of 
these  cavities.  Granulation  tissue  then  encroaches 
upon  the  space  without  hindrance,  and  organisa- 
tion into  fibrous  tissue  or  bone  puts  an  end  to  further 
trouble. 


CHAPTER    XXXYII. 

MOLLITIES    OSSIUM OSTEOMALACIA. 

This  disease  is  more  common  in  females  than  in 
males.  It  affects  chiefly  the  periods  of  early  and 
mid-adult  life  ;  it  is  not  found  in  children.     By  some 


246  Surgical  Pathology.     [Chap.  xxxvii- 

it  is  supposed  to  be  a  premature  senile  decay ;  but 
atrophy  of  the  bones  of  old  people  does  not  as  a  rule 
assume  this  form.  We  may  safely  conclude  that  its 
real  cause  is  unknown. 

Like  rickets,  it  seems  to  be  the  expression  of  a 
general  disease,  or,  at  least,  a  morbid  state  of  the 
osseous  system,  and  not  a  mere  local  or  accidental 
disturbance  of  nutrition  in  one  bone  or  group  of 
bones. 

The  greater  part  of  the  skeleton  may  be  involved ; 
the  vertebrae,  ribs,  pelvis,  and  long  bones  suffer  most ; 
the  bones  of  the  cranium,  carpus,  and  tarsus  enjoy  a 
much  greater  immunity. 

Morbid  anatomy. — In  the  long  bones  the  dis- 
ease commences  in  the  medullary  canal,  and  then 
extends  to  the  medullary  spaces  and  Haversian 
systems  of  the  cancellous,  and  finally  the  compact 
bone. 

The  periosteum  seems  to  take  little  or  no  part  in 
the  process  ;  in  fact,  Rindfieisch  ascribes  to  it  a  con- 
servative roZe,  and  says  that,  by  nourishing  the  peri- 
pheral layers  of  compact  bone,  it  checks,  and  even 
prevents,  the  outermost  laminae  from  being  absorbed 
The  disease  is  a  progressive  one,  and  rarely  stops 
before  the  long  bones  are  hollowed  out  into  mere 
shells,  encased  in  a  parchment-like  layer  of  bone, 
or  riddled  with  cystic  cavities  ("  cystic  degenera- 
tion "). 

Billroth  mentions  two  cases  of  local  osteomalacia 
in  the  long  bones  of  the  extremity ;  but,  as  both  were 
the  subjects  of  caries  of  the  joints,  the  osteoporosis 
was  probably  caused  by  rarefying  ostitis  and  fatty 
atrophy  from  disuse ;  the  microscopy  is  not  given. 

In  the  vertebrae,  pelvis,  sternum,  and  ribs  it  com- 
mences in  several  parts  of  the  cancellous  tissue  at  the 
same  time,  as  shown  by  the  numerous  scattered  exca- 
vations. 


Chap  XXXVII.]         MOLLITIES    OSSIUM. 


247 


Naked-eye  appearances,  etc. — In  the  early 
stage  there  is  very  marked  congestion  of  the  medulla, 
in  the  central  canals  of  the  long  bones,  and  the  medul- 
lary spaces  of  the  cancellous  tissue  generally.  The 
dark-red  colour  seems  to  point  to  the  congestion  being 
passive  rather  than  active.  As  the  vessels  are  imper- 
fectly supported,  capillary  ruptures  take  place.     Later 


^•sir-- 


'^^i>-^^' 
~^^^^ 
"-^^1^ 


Fig.  34.— Mollities  Ossiuni, — Splinter  of  Bone  from  the  Spongy 
Substance  of  an  affected  Eib. 
a,  Normal  Tjone  tissue  ;  6,  decalciQed  bone  tissue  :  c.  Haversian  canal ;  d,  medul- 
lary spaces,  the  one  on  the  left  filled  with  red  marrow.    Tiie  capillary  vessels 
are  gaping  widely.    l-300th.    {.After  Rindfleisch.) 

on,  cystic  cavities  are  formed  by  absorption  of  bony 
trabeculse  and  liquefaction  of  the  medulla.  These  are 
filled  with  an  albuminous  fluid,  clear,  or  turbid  from 
fatty  debris,  and  blood  pigment  the  remains  of  ex- 
travasations. When  the  cysts  cease  to  enlarge  they 
Ijecome  lined  "with  a  fibrous  membrane,  but  little 
vascular.  This  is  derived  from  organisation  of  the 
outer  portion  of  medullary  tissue  that  originally  filled 


248  Surgical  Pathology.    [Chap.  xxxvii. 

the  spaces,  and  from  fibrous  transformation  of  tlie 
decalcified  bone.  The  attenuated  softened  osseous 
trabeculfe  are  so  soft  that  they  may  be  bent  or  cut 
quite  easily. 

Yery  scanty  osteophytes  are  occasionally  deposited 
beneath  the  periosteum  (Billroth). 

ITlicroscopy. — The  capillaries  of  the  afiected 
medulla  in  the  central  canals,  cancellous  spaces,  and 
Haversian  canals,  are  greatly  enlarged.  They  are 
embedded  in  a  soft  gelatinous  substance  composed  of  a 
homogeneous  basis  containing  embryonic  cells,  some 
of  which  are  filled  with  large  fat-drops.  The  cells  are 
much  less  numerous  than  in  caries.  There  are,  be- 
sides, pigment  granules  and  free  blood-corpuscles. 
The  natural  fat  cells  disappear. 

The  bony  trabeculse  bounding  the  spaces  are  some- 
what festooned,  but  to  nothing  like  the  extent  as  one 
sees  in  the  form  of  Howship's  lacunae  from  caries. 
The  lime  salts  are  absorbed  before  the  animal  con- 
stituents, so  that  there  are  two  distinct  zones  around 
the  medullary  spaces,  the  one  composed  of  soft  de- 
calcified bone,  homogeneous  from  obliteration  of  the 
lacunse  and  canaliculi,  the  other  of  healthy  osseous 
laminae  (Fig.  34).  Billroth  defines  the  disease  as  a 
"fungous  fatty  osteomyelitis." 

Cheniisti'y  of tlie  disease. — Rindfleisch  suggests 
that  the  actual  cause  of  absorption  of  the  calcareous 
salts  may  \)%  free  carbonic  acid  contained  in  the  blood 
of  the  congested  medulla.  This  seems  very  doubtful. 
Weber  has  demonstrated  the  presence  of  lactic  acid  in 
the  urine  and  bones,  but  this  is  more  likely  the  con- 
sequence than  the  cause  of  osteomalacia. 

Deformities.  —  As  the  morbid  process  causes 
rarefaction  and  softening,  the  bones  are  rendered 
liable  to  curvatures  and  partial  and  complete  fracture, 
the  sum  total  of  which  is  the  wide- spread  deformities 
of   the    skeleton.      The    mere  weight    of  the    super- 


Chap.  XXXVIII.]     Diseases  of  Joints.  249 

incumbent  parts  and  the  natural  muscular  contractions 
is  sufficient  to  produce  the  most  striking  results ; 
thus  the  ribs  are  bent  by  the  pressure  of  the  arm  in  the 
axillary  line.  They  fall  in  near  their  sternal  ends 
and  along  the  attachment  of  the  diaphragm.  The 
weight  of  the  trunk  increases  the  natural  curves  of 
the  spine,  and  the  vertebrae  at  the  same  time  undergo 
more  or  less  rotation.  The  pelvis  assumes  a  trefoil 
shape  under  the  action  of  three  forces  :  the  weight  of 
the  body,  which  thrusts  the  sacral  promontory  forwards 
and  downwards,  and  the  counter  pressure  through 
the  acetabula. 

The  long  bones  may  be  the  seat  of  many  fractures, 
partial  and  complete. 

Mollities  ossium  contraisted  with  caries. — 
(1)  Mollities  ossium  attacks  many  bones  at  the  same 
time  ;  (2)  each  bone  is  the  seat  of  scattered  foci  of 
absorption  and  excavation ;  (3)  the  lime  salts  are 
absorbed  before  the  organic  constituents ;  (4)  the 
neoplasia  softens  and  liquefies,  but  does  not  caseate  ; 
(5)  the  cavities  formed  in  the  bones  have  regular 
walls,  which  are  sometimes  lined  with  a  fibrous  mem- 
brane ;  (6)  the  disease  has  but  little  tendency  to 
subside ;  and  (7)  it  does  not  begin  nor  spread  beneath 
the  periosteum. 

In  caries  the  reverse  of  the  above  obtains. 


CHAPTER    XXXYIIL 

DISEASES      OF      THE      JOINTS. 

When  studying  the  pathological  changes  going  on 
in  an  inflamed  joint,  it  is  well  to  direct  a  systematic 
attention  to  the  character  of  the  secretion,  the  synovial 
membrane,  articular  cartilage  and  bones,  the  fibrous 


250  Surgical  Pathology.    [Chap,  xxxviii. 

capsule,  and  interarticular  ligaments  where  these  exist. 
It  will  be  found  that  the  anatomical  components  of  a 
joint  are  modified  individually  or  collectively,  in 
different  degrees  and  in  varying  manner,  according  to 
the  nature  of  the  cause  that  sets  up  the  morbid  pro- 
cess ;  e.g.^ 

Simple  traumatic  ai^thritis  is  characterised  by  the 
large  amount  of  serous  exudation,  with  but  little 
tendency  to  the  secretion  of  pus,  whilst  the  cartilage 
and  bone  are  practically  untouched. 

Strumous  arthritis  commonly  ends  in  suppuration 
and  "ulceration  of  cartilage  and  bone." 

Gouty  arthritis  is  marked  by  a  slow,  but  perma- 
nent, change  in  the  articular  cartilage,  deposit  of 
crystals  of  urate  of  soda,  and  recurrent  attacks  of  very 
painful  effusion. 

Pycemic  arthritis  causes  a  marvellously  rapid 
purulent  effusion  from  the  synovial  membrane,  often 
with  comparative  freedom  from  pain. 

In  chronic  rheumatic  arthritis  the  most  noteworthy 
features,  from  a  clinical  point  of  view,  are  the  extreme 
chronicity  and  steady  downward  course ;  from  an 
anatomico-pathological,  the  scantiness  of  the  exudation 
(dry  arthritis),  the  absorption  of  the  articular  car- 
tilages, the  eburnation  of  the  bones,  and  the  exuberant 
growth  of  osteophytes. 

Gonorrhaeal  rheumatism,  is  often  verv  intract- 
able,  and  liable  to  recur  again  and  again. 

etiology. — The  causes  of  arthritis  may  be 
classified  as  follows  : — 

1.  Traumatism,  including  the  cases  that  arise  from 
the  spreading  of  inflammation  in  the  continuity  of 
tissue  from  other  parts  ;  e.g.,  Si  diseased  bone. 

2.  Acute  blood-poisoning :  (a)  the  acute  specific 
fevers;  and  (b)  pyaemia  and  syphilis,  gonorrhoea  (1). 

3.  Diathetic  states:  gout,  rheumatism,  scrofula, 
haemophilia. 


Chap.  XXXIX.]      Strumous  Arthritis.  251 

4.  Trophic  lesions  and  vaso-motor  paralyses  :  loco- 
motor ataxia. 

5.  Degeneration  from  old  age  :   "  senile  scrofula." 
Notice  of  the  previous   state   of  nutrition    of   the 

articular  structures  must  not  be  omitted.  When  we 
say  that  a  certain  poison  selects  a  certain  tissue  for  its 
local  manifestation,  the  truth  is  only  half  expressed. 
The  tissues  play  a  very  important  part  in  the  history 
of  the  causation  of  their  morbid  states.  This  is 
nowhere  better  exemplified  than  in  the  joints.  In  gout 
there  is  a  great  predilection  for  the  metatarsal  articu- 
lation of  the  great  toe.  In  scrofula  it  is  the  hip, 
knee,  and  the  joints  of  the  hands  and  feet ;  in  dry 
arthritis  the  hip,  shoulder,  knee,  and  temporo-maxil- 
lary  articulation,  and  the  digits ;  in  gonorrhceal 
rheumatism  the  knee  and  wrist.  Previous  disease, 
whilst  it  increases  the  liability  to  subsequent  attacks, 
seems  to  confer  a  quantitative  protection  in  some 
cases.  Thus,  if  a  healthy  joint  be  wounded,  there  is 
great  danger  of  acute  destructive  inflammation,  gene- 
ral constitutional  disturbance,  and  high  fever.  It  is 
very  diflferent  in  the  case  of  one  damaged  by  chronic 
strumous  arthritis.  A  parallel  case  is  that  furnished 
by  the  normal  peritoneum  and  an  old  thickened  her- 
nial sac. 


CHAPTER    XXXIX. 

STRUMOUS    ARTHRITIS. 

Synonyms. — White  swelling  ;  fungous  disease  or 
pulpy  degeneration  of  the  synovial  membrane ;  ulcera- 
tion of  cartilage. 

Causes. — The  disease  is  common  in  patients  of 
obvious  strumous  diathesis.  It  is  likewise  met  with 
where  there  is  no  other   departure  from  good   health. 


252  Surgical  Pathology.      [Chap.  xxxix. 

It  may  be  traceable  to  an  injury  as  the  exciting  cause. 
(Vide  Scrofula.) 

Morbid  anatomy. — The  disease  begins  in  the 
synovial  membrane  or  the  bone,  never  in  the  cartilage. 

Pathologists  differ  as  to  the  relative  degree  of  frequency 
of  the  two  sources.  Many  believe  that  in  a  great 
majority  of  cases  it  starts  in  the  synovial  membrane. 
My  own  observations  lead  me  to  conclude  that  in  not 
a  few  instances  the  bone  is  primarily  affected,  especi- 
ally in  the  carpus  and  tarsus.  In  the  hip  joint  the 
ligamentum  teres  is  sometimes  held  to  be  the  seat  of 
the  initial  lesion,  but  then  it  is  really  the  synovial 
membrane  that  surrounds  the  ligament. 

At  first  the  synovial  memhrane  is  of  a  bright  pink 
colour  ;  it  looks  glistening,  and  is  slightly  swollen. 
The  microscope  shows  dilatation  of  the  capillaries  and 
some  leucocytes.  Later  on,  the  swelling  becomes 
more  marked  ;  the  surface  endothelium  is  shed,  and 
the  meshwork  of  areolar  tissue  is  no  lonoer  visible. 
Its  fibres  have  softened,  melted  away,  and  the  whole 
is  overrun  with  wandering  cells.  In  short,  the  folds 
and  fringes  have  been  converted  into  a  pulpy  reddish 
grey  mass  of  gelatinous  granulation  tissue. 

By  this  time  the  cartilage  is  involved  at  the 
periphery ;  it  has  lost  its  pearly  lustre  and  firm 
consistence.  The  change  consists  of  a  mucoid  lique- 
faction of  the  matrix  and  a  proliferation  of  the  cells. 
Vertical  sections  show  successively  from  the  free 
surface  a  layer  of  indifferent  cells,  broods  of  cells  in 
process  of  joining  one  another,  cartilage  corpuscles  in 
various  stages  of  segmentation,  and  healthy  cartilage. 

The  fiuid  in  the  joint  is  now  thin  and  cloudy,  or 
seropurulent  from  the  presence  of  leucocytes  and  fat 
particles. 

The  fungous  granulation  tissue  goes  on  increasing 
by  the  development  of  new  vessels  and  continued 
exudation    until   it  fills   all  the  crevices  of  the  joint, 


Chap.  XXXIX.]      Strumous  Arthritis. 


25; 


pushing  its  way  between  the  bones,  and  rooting  its 
vessels  in  the  softened  cartilage  as  it  passes  over  it. 
At  length  the  entire  thickness  of  cartilage  is  destroyed 
in  patches,  and  the  bone  is  attacked  with  rarefying 
ostitis  (caries). 

In  some   cases  the   cartilage  is   absorbed    on   the 
articular  and  osseous  surfaces  at  the  same  time,  so 


Fig.  35. — Diagram  of  a  Section  of  a  Knee-joint  (the  Interarticular  Carti- 
lages have  been  left  out,  the  Articular  Cartilages  shaded),  with 
Fungous  Inflammation. 

a,  a.  Fibrous  capsule  ;  6,  crucial  ligament ;  c,  femur;  d,  tihia  ;  e,  e,  fungous  syno- 
A'ial  membrane  growing  into  tlie  cartilage ;  at/  it  even  grows  into  the  bone  ; 
at  f/  are  isolated  proliferations  of  the  granulations  into  the  bone  on  the  border 
between  bone  and  cartilage.    {After  Billroth.) 


that  flakes  are  set  free  in  the  j  oint,  whilst  other  por- 
tions are  so  loosened  from  their  attachment  to  the 
bone,  that  the  handle  of  a  scalpel  can  be  readily 
thrust  between  the  two  structures  (Fig.  35).  The 
older  pathologists,  struck  by  this  state  of  things, 
named  the  disease  "  ulceration  of  cartilage,"  but,  as 
before  said,  this  is  always  secondary  to  fungous 
synovitis  or  ostitis. 


254  Surgical  Pathology.      [Chap.  xxxix. 

"  Starting "  pains  indicate  not  only  that  the  car- 
tilage is  "ulcerated,  but  that  the  bones  are  exposed  in 
the  joint. 

By  this  time  the  joint  usually  contains  pus,  and 
molecular  and  shreddy  debris  of  broken-down  granula- 
tion tissue  and  cartilage.  Instead  of  diffuse  sup- 
puration, localised  abscesses  may  form  in  succession  in 
different  parts  of  the  joint,  open  externally,  discharge 
for  a  while,  and  then  close,  leaving  the  permanent 
cicatrices  in  the  soft  parts,  so  often  seen  about  partially 
dislocated,  stiff,  or  anchylosed  joints. 

When  the  bones  are  diseased,  either  primarily  or 
as  the  result  of  extension  of  inflammation  from  the 
joint,  they  are  affected  with  fungous,  atonic,  and  not 
seldom  necrotic  caries  {q.v.). 

The  capsule  is  softened  and  thickened.  On  section 
it  looks  gelatinous.  It  is  stretched  by  the  pressure 
from  within,  except  on  the  aspect  of  flexion,  where  it 
is  more  or  less  contracted. 

The  tissues  around  suffer  considerably. 

The  muscles  waste  from  disuse.  They  become 
fatty,  and  undergo  interstitial  cicatricial  absorption ; 
hence  the  shortening. 

The  subcutaneous  tissue  is  congested  and  oedem- 
atous.  Except  in  very  acute  cases,  tJie  skin  retains  its 
white  appearance  (tumor  albus).  The  ends  of  the  hones 
appear  enlarged,  but  this  is  fallacious.  It  is  due  to 
swelling  of  the  soft  parts  and  the  shrinking  of  the 
muscles. 

Abscesses  not  unfrequently  form  outside  the  arti- 
cular capsule. 

Flexion  and  dislocation  of  tlie  joint;  e.g., 
the  knee.  Flexion  is  caused  by  reflex  contraction 
of  the  muscles  (Hilton),  and  by  the  hydrostatic  pres- 
sure of  the  effusion  within  the  joint  (Bonnet).  The 
head  of  the  tibia  is  rotated  out,  and  displaced  back- 
wards and  outwards.   Several  forces  concur  in  effecting 


Chap.  XXXIX.]       StRUAWUS    ARTERITIS. 


255 


this — atrophic  contraction  of  the  muscles,  shrinking 
of  the  capsule  and  external  ligaments,  destruction  of 
the  crucial  ligaments,  and  the  weight  of  the  limb. 


Fig.  36. — Hip  joint  affected  with  Strumous  Arthritis. 

Theliead  of  the  femur,  a,  has  lost  its  cartilage  ;  the  articular  surface  is  composed 
of  porous,  rarefied,  cancellous  tissue;  the  upper  and  posterior  part  of  the 
acetabular  rim  has  been  absorbed  by  the  joint  action  of  the  carious  process 
and  the  continuous  pressure  of  the  head  of  the  femur;  6,  buttress  of  bouf-, 
composed  of  sharp  stalactitic  osteophytes  thrown  out  to  support  the  dislo- 
cated head.    (One-third  natural  size.) 


Terminations  of  the  disease. — It   may   be 

arrested  at  any  stage,  perfect  movement  may  be  re- 
stored ;  more  often  stiffness  remains.  Anchylosis  is 
not  uncommon.  In  this  case,  the  granulation  tissue 
between  the  bones  organises  to  fibrous  tissue  or  bone. 
Suppuration  and  complete  destruction    of    the   joint 


256  Surgical  Pathology.  [Chap.  xl. 

with  extensive  disease  of  the  bones  is  far  from 
rare. 

Hip-joint  disease. — In  some  works  the  minute 
anatomy  of  hip-joint  disease  is  given  at  great  length, 
as  though  it  constituted  a  special  disease.  This  is  not 
the  case.  It  is  fungous  arthritis  (white  swelling),  and 
begins,  as  before  said,  either  in  the  synovial  mem- 
brane or  the  bone,  as  implied  in  the  enumeration  of 
the  "  articular,"  "  femoral,"  and  "  acetabular  "  varie- 
ties. What  makes  the  affection  of  so  much  importance 
is  its  frequency,  anatomical  complexity,  and  clinical 
gravity. 

The  abscesses  that  form  in  connection  with  the 
disease,  open  above  and  behind  the  great  trochanter, 
or  in  the  groin,  following  the  course  from  the  joint 
taken  by  the  internal  circumflex  artery. 

When  the  acetabulum  is  extensively  diseased,  pus 
often  collects  within  the  pelvis,  and  the  head  of  the 
femur,  or  what  remains  of  it,  is  sometimes  forced 
through  the  bottom  of  the  cavity  by  the  functional 
and  atrophic  contraction  of  the  muscles. 


CHAPTER  XL. 

CHRONIC    RHEUMATIC    ARTHRITIS. 

Synonyms. — Arthritis  deformans,  proliferating 
arthritis,  dry  arthritis,  nodular  rheumatism,  malum 
coxae  senilis,  rheumatic  gout.  These  terms  refer  to 
some  points  in  the  clinical  or  pathological  history  of 
the  disease,  which,  although  in  the  gross  it  presents 
wide  structural  variations,  is  sufficiently  well  defined 
in  its  general  features  and  anatomical  lesions. 

Causes. — The  etiology  is  obscure  as  regards  the 
immediate  cause  of  the  particular  tissue  change.     It 


Chap.  XL.]    Chronic  Rheumatic  Arthritis.       257 

is  met  with  chiefly  in  persons  beyond  mid-life,  and 
in  those  exposed  to  inclemencies  of  climate. 

The  disease  occurs  under  two  forms,  according  as 
it  is  localised  in  one  or  more  points. 

In  the  former  case  it  attacks  the  large  joints, 
especially  the  hip,  and  as  it  is  incidental  to  advanced 
age  it  has  been  called  morbus  coxae  senilis.  It  is 
chronic  from  the  first,  and  is  rarely  traceable  to 
injury. 

The  polyarticular  variety  is  found  in  the  small 
and  medium-sized  points,  those  of  the  digits  in 
particular.  It  affects  the  young  and  middle-aged 
rather  than  the  old,  women  more  often  than  men.  It 
begins  as  a  distinct  affection,  or  it  is  the  sequel  of 
acute  articular  rheumatism. 

Tflorbid  anatomy. — In  the  majority  of  cases 
the  cartilages  are  first  affected,  but  the  synovdal  mem- 
brane, bones,  and  ligaments  soon  become  involved. 
However  extreme  the  lesion,  it  never  ends  in  sup- 
puration. In  this  way  it  stands  in  marked  contrast 
to  strumous  arteritis. 

The  disease  is  characterised  by  (1)  a  proliferation 
and  subsequent  destruction  of  the  articular  cartilage ; 
(2)  by  eburnation  of  the  ends  of  th€  bones ;  (3)  by 
the  formation  of  ecchondroses  and  massive  rounded 
osteophytes  ;  (4)  by  chronic  inflammatory  hypertrophy 
of  the  synovial  membrane. 

The  joints  of  the  fingers  and,  less  frequently,  the 
toes  become  knobbed,  stiff,  and  contracted — rheu- 
matismus  nodosus. 

Chang^es  in  the  cartila§:e. — These  are  essen- 
tially proliferating  or  constructive  ;  but,  inasmuch 
as  the  consistence  is  diminished,  the  new-formed  cells 
and  softened  matrix  are  gradually  worn  away  and 
finally  destroyed  altogether,  leaving  the  bone  exposed 
and  condensed. 

The  surface   layer  of  cells  is  first  affected.     The 

R 


258 


Surgical  Pathology. 


[Chap.  XL. 


cells  multiply  by  segmentation,  but  so  slowly  that 
instead  of  forming  small  round  unstable  granulation 
corpuscles,    as    is    the    case    in   white    swelling,   they 

assume  more  or  less  the 
characteristics  of  cartilage 
elements. 

The  primary  capsules 
enlarge  and  fill  with 
numerous  secondary  cap- 
sules. The  secondary  cap- 
sules are  contained  one 
within  another,  forming 
a  series  of  concentric 
rings,  or  they  remain  iso- 
lated within  the  primary 
capsules,  or,  if  this  has 
disappeared,  in  one  large 
capsule. 

By     softening     of    the 


Fig.  37. — Nodular  Eheumatism. 
Surface  of  the  Cartilage. 


a,  Primary  capsule  filled  with  second-  matrix,     the      SpaCCS       filled 

ar>- capsules  about  to  open  into  the  ',^                                       i                   i 

articulation ;  b,  segmented  matrix.  With       UCW        CapSUiCS      and 

Magnified    200     diameters.      [After  ,,                   .             ■*■                   , 

Cornil  and  Ranvier.)  CCliS  OpCU  mto  OnC  another, 

constituting  alveolar  spaces 
perpendicular  to  the  articular  surface  ;  very  similar 
to  what  takes  place  at  the  border  of  normal  ossi- 
fication of  bone,  and  in  the  epiphysial  cartilages 
in  rickets.  The  superficial  capsules  dissolve  and  set 
their  contents  free  into  the  joint,  leaving  soft  wavy 
villous  processes  of  the  matrix. 

The  more  or  less  parallel  and  vertical  arrange- 
ment of  the  cells,  groups,  and  bands  of  matrix  is  due 
(1)  to  the  lateral  resistance  to  expansion  of  the  en- 
larging capsules  ;  (2)  to  the  normal  construction  of 
cartilage,  which,  although  it  appears  homogeneous  on 
section,  is  seen  on  fracture  to  consist  of  columns  set 
at  right  angles  to  the  bone,  i.e.,  in  the  direction  of 
greatest  pressure.     At  length  the  bone  is  exposed. 


Chap.  XL.]   Chronic  Rheumatic  Arthritis.        259 


Chang^es  in  the  subcai^tilaginous  bone. — 

This  also  undergoes  inflammatory  absorption,  but  as 
the  vascularisation  and  initial  rarefaction  are  out- 
stripped by  the  condensation  immediately  below  the 
surface,  the  spongy  cancellous  tissue  is  not  exposed. 
The  sclerosinf;  ostitis  causes  ebumation.  The  bone  is 
gradually  worn  away  and  polished  by  friction,  either. 
uniformly  or  in  fuiTOws. 

Cliang^es  in  tlie  synovial  membrane. — The 
synovial    membrane    becomes    more    vascular,     and 

stand  out 


swollen  and  thickened, 
as  club-shaped  protru- 
sions. I^Tew  processes 
are  given  off  from  the 


The  villi  or  fringes 


so    that   a 
appearance 


old    ones, 
branched 

is  produced  ( "  arbor- 
escent budding"). 

The  fat  cells  dis- 
appear, and  their  place 
is  taken  by  exudation 
corpuscles,  some  of 
which  escape  into  the 
joint,  and  render  the 
fluid,  now  increased 
in  quantity,  more  or 
less  turbid.  But  the 
greater  part  of  the  in- 
flammatory neoplasia 
organises  into  dense 
connective  tissue. 

Some  of  the  indiffer- 
ent corpuscles  develop 
into  cartilage,  so  that 

nodules    are    formed,   and  these    remain   isolated,  or 
coalesce  into  thick  tuberculated  laminEe. 

Meanwhile,   the   lateral   portions   of  the   articular 


Fig.  38. 


-Hip  joint  affected  with  Chronic 
Eheiimatic  Arthritis. 

rt.  Articular  surface  of  the  femur  denuded  of 
its  cartilage,  t)ut  smooth  from  the  ehurna- 
tion  consequent  on  sclerosing  ostitis;  6, 
rounded  osteophytes.  Compare  this  figiire 
with  Fig.  36.    (One-third  natural  size.) 


26o  Surgical  Pathology.  [Chap.  xl. 

cartilages,  less  subject  to  pressure  and  friction  than 
the  central  part,  whilst  they  proliferate,  are  not  worn 
away,  but,  being  soft,  they  yield  like  indiarubber  to  a 
force  insufficient  to  cause  their  destruction.  Thus  the 
articular  surface  of  the  bone  is  greatly  widened.  In 
the  case  of  the  hip  joint  the  cartilage  (subsequently 
bone)  droops,  like  a  mantle  with  wavy  border,  from 
the  head  of  the  femur. 

The  cartilaginous  growths  in  the  synovial  mem- 
brane sometimes  form  pedunculated  masses.  They 
frequently  calcify,  and  ossify  into  spongy  bone.  They 
are  liable  to  be  detached  and  roll  free  in  the  joint  as 
foreign  bodies.  They  sometimes  appear  as  though 
"  glued  on  to  the  bone." 

The  i^ecretiou  in  the  joint  is  thin,  and  clear  or 
cloudy,  never  purulent.  In  some  instances  it  is  con- 
siderably increased,  especially  in  the  earlier  stages  of 
the  inflammation.  In  others  there  is  scarcely  any  at 
all ;  this  is  notably  the  case  in  the  polyarticular 
variety,  which  aflects  the  digits  (dry  arthritis). 

The  exti'a-articiiiar  structures. — The  muscles 
of  the  limb  waste  from  disuse.  The  ligaments  become 
dense  and  contracted,  frequently  ossified ;  so  also  the 
tendons  attached  to  the  bones  around  the  affected  joint. 

Osteophytes  spring  up  from  the  periosteum,  and 
grow  into  the  articular  capsule.  Many  are  isolated, 
and  lie  at  some  little  distance  from  the  joint. 

The  absorption  of  the  head  and  shortening  of  the 
neck  of  the  bone,  together  with  the  extensive  out- 
growths, give  to  the  hip  joint,  e.g..,  a  remarkable 
appearance,  justifying  the  name,  arthritis  deformans. 


26l 


CHAPTEK  XLI. 

ACUTE    SEROUS    SYNOVITIS HYDROPS    ACUTUS. 

Take,  &.g.y  the  knee  joint  that  has  been  injured  by 
a  blow  or  strain,  or  that  has  inflamed  from  exposure 
to  wet  and  cold ;  it  soon  becomes  painful,  especially 
on  movement,  so  that  walking  is  diificult.  The  pain 
is  of  an  aching  character,  from  stretching  of  the 
nerves.  Swelling  comes  on  very  cjuickly,  and  so 
rapid  is  the  effusion  that  the  lateral  depressions  by 
the  patella  and  patellar  ligament,  and  the  pouch 
beneath  the  triceps  muscle,  may  be  raised  into  pro- 
minences in  a  few  hours. 

The  skin  over  the  joint  retains  more  or  less  its 
natural  colour.  The  joint  is  somewhat  flexed,  but 
not  to  the  extent  that  is  found  in  acute  suppurative 
arthritis,  although  the  amount  of  fluid  it  contains  may 
be  much  greater  than  in  the  more  severe  affection. 
This  seems  to  prove  conclusively  that  the  chief  cause 
of  the  flexion  lies  in  the  reflex  contraction  of  the 
muscles  set  up  by  the  irritation  of  the  nerves  supplied 
to  the  synovial  membrane. 

If  the  fluid  be  drawn  off  by  the  aspirator  it  will  be 
found  to  be  clear,  or  slightly  cloudy,  from  shedding  of 
the  synovial  endothelium,  exudation  of  leucocytes,  and 
it  may  be  coagulation  of  fibrin  in  fine  flakes,  and  for- 
mation of  strings  of  mucin. 

If  such  a  joint  be  opened  the  synovial  membrane 
will  be  found  to  be  uniformly  pink,  puffy,  and  gela- 
tinous, showing  few  or  no  signs  of  suppuration  or 
disintegration.  Under  the  microscope  the  fibrous 
element  looks  glassy,  and  is  seen  to  contain  exudation 
cells. 


262  Surgical  Pathology.         [Chap.  xlil 

The  articular  cartilage  is  cloudy  on  the  surface, 
perhaps  a  little  softened.  The  superficial  cells  are 
granular  and  swollen,  and  sometimes  in  process  of 
segmentation.  The  primary  cartilage  capsules  are 
enlarged  ;  the  secondary  ones  more  numerous.  The 
matrix  is  somewhat  fibrillated. 

Such  a  case  resembles  inflammation  of  the  large 
serous  membranes  (pleurae,  pericardium)  in  the 
rapidity  with  which  the  synovial  membrane  pours  out 
large  quantities  of  fluid. 

Unless  the  articular  lesion  is  the  result  of  acute 
rheumatism,  the  constitutional  disturbance  is  not  great. 

As  the  inflammation  resolves  the  pain  goes,  and 
the  function  of  the  joint  is  restored.  Frequently, 
however,  it  subsides  into  the  chronic  form,  the  fluid 
remaining  in  excess. 


CHAPTER  XLII. 

CHRONIC   SEROUS    SYNOVITIS. 

This  disease,  called  also  hydrops  articulorum,  is 
either  the  sequel  of  acute  or  subacute  synovitis,  or  it 
is  chronic  from  the  first.  It  is  generally  met  with  in 
the  knee  joint,  and  it  affects  by  preference  young 
adult  males.  The  signs  of  inflammation  (save  one, 
swelling)  are  so  little  marked  that  some  pathologists 
rega.rd  the  inflammation  as  a  simple  dropsy,  analogous 
to  hydrocele  of  the  tunica  vaginalis  testis  ;  but  from 
the  fact  that  it  is  often  the  remains  of  a  more  acute 
process,  and  that  in  a  series  of  cases  every  gradation 
may  be  met  with,  from  a  slow  painless  effusion  to  a 
fairly  rajoid  exudation,  accompanied  by  increased  heat 
of  the  joint,  this  view  seems  untenable. 

Morbid  anatomy. — The  jiiiid  may  be  slightly 
viscid,  but  as  a  rule  it  is  thin  and  serous.  The  synovial 


Chap.  XLiii.]     Suppurative  Arthritis.  263 

membrane  is  slightly  swollen  and  cedematous.  In  old 
cases  it  is  somewhat  indurated  from  the  growth  of  a  low 
form  of  connective  tissue,  but  it  never  presents  the 
gelatinous  fungous  appearance  of  white  swelling,  and 
the  tendency  to  suppurate  is  almost  nil.  The  capsule 
is  stretched,  but  the  joint,  though  crippled  me- 
chanically, is  very  little,  if  at  all,  painful.  The  spon- 
taneous form  of  the  disease  is  often  symmetrical. 
This  points  to  an  inherent  weakness  of  tissue,  or  to 
some  constitutional  disorder. 


CHAPTEE,   XLIII. 

PHLEGMONOUS    OR    SUPPURATIVE    ARTHRITIS. 

Causes  :  (1)  Severe  injury,  especially  wound  of 
the  joint ;  (2)  spreading  of  acute  inflammation  from 
the  bones  or  soft  parts ;  (3)  some  infective  material  in 
the  blood,  that  of  pyaemia,  or,  more  rarely,  acute 
rheumatism,  or  the  specific  fevers. 

Suppurative  artliritis  firom  purulent  in- 
feetiou  sets  in  very  rapidly ;  the  joint  may  be  dis- 
tended with  pus  in  a  few  hours.  In  these  cases 
the  synovial  membrane  is  injected  and  swollen,  but 
not  to  the  extent  that  one  would  expect  from  the 
amount  of  exudation.  The  cells  are  mainly  derived 
from  the  vessels  of  the  synovial  membrane.  Segmen- 
tation of  the  cells  of  the  articular  cartilage  furnishes 
others  when  this  structure  is  softened  and  eroded. 
There  may  be  embolic  infarctions  and  localised  dis- 
integrations of  synovial  membrane;  but  this  is  the 
exception. 

Traumatic  suppurative  arthritis.  —  Here 
the  joint   is   intensely   painful,   sharply   flexed,   and 


264  Surgical  Pathology.       [Chap.  xliii. 

immovable  from  spastic  contraction  of  the  muscles. 
The  outline  is  more  or  less  globular ;  for  the  capsule, 
subcutaneous  cellular  tissue,  and  skin  are  all  injected 
and  inflamed ;  hence  the  elevations  caused  by  the  dis- 
tention of  the  synovial  pouches  are  lost  in  the  general 
swelling. 

The  synovial  membrane  is  intensely  red,  puffed, 
and  pulpy.  It  may  contain  yellowish  foci  of  minute 
interstitial  suppuration.  The  vessels  are  dilated  and 
pouched  ;  in  some  stasis  has  occurred.  The  surface 
has  lost  its  polish. 

The  cartilage. — This  is  obviously  affected;  the 
superficial  portion  is  softened,  pulpy,  and  either 
granular  or  slightly  villous.  The  microscope  shows 
an  active  proliferation  of  the  cells,  and  a  homoge- 
neous or  fibrillar  appearance  of  the  matrix.  The  secon- 
dary capsules  are  dissolved,  and  the  primary  ones 
filled  with  granulation  cells.  Next  the  joint,  no  trace 
can  be  seen  of  the  original  structure  ;  nothing  but  a 
layer  of  indifferent  cells  imbedded  in  the  liquefied 
matrix. 

The  inflammation  of  the  cartilage  is  secondary  to 
that  of  the  synovial  membrane,  and  is  set  up  by  the 
irritation  of  the  secretion  poured  out  by  the  latter. 

The  articular  cajosule  is  thick  and  gelatinous,  and 
the  surrounding  cellular  tissue  congested  and  oedema- 
tose. 

The  contents  of  the  joint  consist  at  first  of  an 
increased  synovial  secretion.  Very  soon  the  cavity  is 
filled  with  pus. 

If  the  inflammation  is  allowed  to  go  on  unchecked, 
the  cartilages  are  entirely  destroyed  and  the  bones 
exposed ;  the  capsule  softens,  and  is  converted  into 
granulation  tissue ;  the  suppuration  is  no  longer  con- 
fined to  the  joint,  but  extends  rapidly  beneath  the 
fascia  around,  or  an  external  opening  is  formed,  and 
so  the  tension  is  relieved. 


Chap.  XLIV.]     GONORRHCEAL    RHEUMATISM.  265 

There  is  severe  constitutional  disturbance,  with 
high  fever,  the  result  of  absorption  of  pyrogenous 
material  and  the  acute  pain. 


CHAPTEPv   XLIY. 

GONORRHCEAL   ARTHRITIS,  GOXORRHCEAL    RHEUMATISM. 

GoNORRHCEAL  rheamatism  is  generally  considered 
to  be  a  mild  form  of  pyaemia,  due  to  purulent 
absorption  from  the  inflamed  urethra.  Many  eminent 
authorities  hold  that  gonorrhoea  itself  is  not  a  specific 
disease,  but  a  simple  acute  suppurative  urethritis. 

It  occurs  in  only  a  fractional  percentage  of  persons 
aflfected  with  gonorrhcea,  and  must  therefore  be  sup- 
posed to  result  from  some  accidental  alteration  in  the 
composition  of  the  secretion;  or,  what  is  far  more 
probable,  from  a  disposition  of  the  synovial  membrane 
in  certain  individuals  to  become  inflamed  on  slight 
irritation.  Painful  swelling  of  the  joints  is  far  from 
rare  in  many  inflammatory  diseases,  particularly  those 
attended  with  suppuration.  The  simple  passage  of  a 
catheter  has  been  known  to  produce  the  same  result. 
The  disease  is  sometimes  very  obstinate,  and  is  liable 
to  recur  long  after  the  original  cause  has  disappeared, 
and  is  almost  certain  to  do  so  if  it  be  renewed. 

It  may  be  accompanied  by  inflammation  of  the 
sclerotic  coat  of  the  eye-ball. 

The  pathological  changes  are  the  same  as  in  acute 
and  subacute  synovitis  arising  from  other  sources. 

The  knee  joint  is  more  often  affected  than  any 
other ;  the  writer  has  seen  it  in  the  elbow  and  wrist. 

The  inflammation  generally  subsides  after  a  time, 
but  it  may  go  on  to  complete  destruction  of  the  arti- 
culation. 


266 
CHAPTEK  XLV. 

HEMORRHAGE    INTO    JOINTS. 

Causes  :  (1)  Injury ;  (2)  rupture  of  a  popliteal 
aneurism,  into  the  knee  joint ;  (3)  haemophilia ;  (4) 
some  blood  diseases,  e.g.,  scurvy. 

Traiamatic  lisemartlu^osis.  —  This  follows 
blows  on  the  joint.  The  extravasation  takes  place 
fi-om  the  capillaries  of  the  synovial  membrane,  and, 
in  the  knee  joint,  from  the  broken  surfaces  of  a 
fractured  patella.  It  is  diagnosed  from  serous  effusion 
by  the  fluctuation  being  less  marked,  and  the  rapidity 
with  which  the  swelling  follows  the  injury. 

As  a  rule,  the  blood  is  entirely  absorbed,  but  occa- 
sionally fibrinous  coagula  remain. 

Msemorrtiag^e  from  liseinopliiliaL  is  most 
common  in  the  knee  joint.  It  is  followed  by  a 
certain  amount  of  synovitis. 

Haemophilia  is  eleven  times  as  fi-equent  in  males 
as  in  females,  though  the  latter  usually  transmit  the 
disease  (W.  Legg).  Beyond  its  consequences,  the 
morbid  anatomy  is  unknown. 


CHAPTER   XLYI. 

LOOSE    OR    MOVABLE    BODIES    IN   JOINTS. 

These  are  of  different  kinds :  (1)  The  most 
common  are  termed  melon-seed  bodies,  on  account  of 
their  prevailing  shape,  rounded  at  one  end,  somewhat 
acuminate  at  the  other,  and  flattened.  Some  are  as 
small  as  a  hemp  seed,  others  are  many  times  as  large. 

A  healthy  synovial  membrane  is  finely  fimbriated ; 


Chap.  XLVL]       MOVABLE   BODIES   IN  JOINTS. 


267 


the  primary  fringes  consist  of  delicate  areolar  tissue, 
covered  by  a  layer  of  endothelial  cells ;  and  loops  of 
capillary  vessels.  The  secondary  fringes  are  sometimes 
extravascular  (Rainey).  Kolliker  has  shown  that  the 
synovial      pro-  y<^^Jp^^^ 

cesses  occasion- 
ally contain  a 
few  cartilage 
cells. 

Whe  ther 
from      chronic 
inflammation 
or   a  pure  hy- 
pertrophy, 
part      or 
whole      of 
synovial   mem- 
bi-ane  of  a  joint 
may  be  covered 
with  small   pe- 
d  u  n  c  u  1  a  t  e  d 
bodies(Fig.39). 

The  pedicles 
are  often  ex- 
tremely fine, 
and  the  least 
force  suffices  to 
rupture  them. 
The  melon-seed 
bodies,  then, 
are  clearly  en- 
larged synovial 
fringes.  Their  microscopical  structure  varies  ;  in  most 
cases  they  show  nothing  but  a  dense  homogeneous  fi.bri- 
nous  material ;  sometimes  there  is  a  faint  concentric 
lamination ;  very  rarely  cartilage  cells  can  be  seen. 

(2)  Rounded  or  nodular  masses  of  a  gelatinous 


Fig.  39. — Hypertrophy  of  the  Synovial  Fringes 
of  the  Knee  Joint. 

a,  Articular  surface  of  the  femur;  &,  patella;  c,  liga- 
mentum  patellae  ;  d,  portion  of  capsule. 


2  68  Surgical  Pathology.       [Chap.  xlvii. 

substance,  devoid  of  any  trace  of  organised  structure. 
They  are  either  fibrinous  exudations  from  the  synovial 
membrane,  or  swollen  degenerated  synovial  fringes  (1 
and  2  are  also  found  in  synovial  sheaths,  ganglia,  and 
mucous  bursse). 

(3)  Bodies  of  much  larger  size  than  any  of  the 
foregoing,  consisting  of  hyaline  or  fibrous  cartilage, 
either  in  the  natural  state,  or  ossified,  or  calcified. 
They  are  detached  from  arborescent  outgrowths  of  the 
synovial  membrane,  and  nodular  thickenings  of  the 
lateral  portions  of  the  articular  cartilages  in  chronic 
rheumatic  arthritis. 

(4)  Lipomatous  bodies,  hypertrophies  of  the 
cellulo-adipose  tissue  of  the  synovial  membrane. 

(5)  Portions  of  articular  cartilage  split  off  by 
accident,  or  set  free  by  ulceration  (white  swelling). 

(6)  The  remains  of  blood-clots. 

Groups  1,  2,  and  3  are  chiefly  met  with  in  the 
knee  joint. 


CHAPTER  XLYII. 

ON    DEFOEMITIES. 

Amongst  the  deformities  of  greatest  interest  to  the 
surgeon  are  those  involving  :  (1)  Malposition  of  the 
bones  entering  into  the  articulations  of  the  extremities ; 
and  (2)  curvatures  of  the  spine. 

The  shape  of  the  bones  may  remain  unaltered ;  or 
it  may  deviate  widely  from  the  normal,  as  a  part  of 
the  initial  lesion,  or  as  a  secondary  result  of  mis- 
directed and  excessive  pressure. 

Causes, — The  causes  of  deformities  are  numerous : 

(1)  Arrested  or  perverted  development  during  intra- 
uterine life.  Such  are  the  congenital  defects  in  the 
different  varieties  of  club-foot,  dislocation  of  the  hip. 


Chap.  XL VI I.]  On  Deformities.  269 

spina  bifida,  and  meningocele  (cerebral).  That  most 
of  the  forms  of  club-foot  are  due  to  abnormal  fcetal 
evolution  is  shown  by  the  great  regularity  of  disposi- 
tion of  the  structures  implicated  ;  thus  we  come  to 
arrange  them  in  certain  well-defined  groups.  Again, 
the  most  common  (talipes  equino- varus)  is  mainly  an 
exaggeration  of  the  position  assumed  during  complete 
rest,  ^.e.,  when  all  voluntary  muscular  action  is  with- 
drawn, as  in  the  cadaver.  Diefienbach  says  "  that  all 
children  are  born  with  the  first  stage  of  club-foot." 
This  is  only  true  in  a  physiological  sense,  for  when 
the  child  comes  to  walk  the  foot  takes  its  natural 
position  without  let  or  hindrance  from  alteration  in 
the  form  of  the  articular  surfaces  of  the  bones,  or 
contraction  of  ligaments,  or  paralysis  or  shortening 
of  muscles.  In  early  fcetal  life  the  back  of  the  lower 
extremity  lies  in  contact  wdth  the  belly,  and  in  very 
rare  cases  it  has  been  known  to  be  fixed  there  by 
integument  common  to  it  and  the  trunk.  As  develop- 
ment goes  on  the  limh  rotates,  so  that  the  calf  comes 
to  look  backwards,  and  the  sole  of  the  foot  downwards. 
Talipes  equino-varus  may  be  considered  as  the  result 
of  imperfect  rotation.  It  is  not  uncommon  for  spina 
bifida  to  be  associated  with  some  variety  of  club-foot, 
and  pathologists  have  sought  to  connect  the  two,  by 
supposing  that  the  latter  is  due  to  perverted  innerva- 
tion. But  club-foot  usually  occurs  without  any  other 
sign  of  disease  of  the  spinal  centres  or  nerves.  In  one 
case  I  found  the  brain  and  cord  absent,  adhesion  of 
certain  fingers  to  the  palm,  extroversion  of  the 
bladder,  and  talipes  calcaneus.  It  seems  far  more 
probable  that  the  spinal  and  pedal  deformities  are 
mere  coincidences,  than  that  they  stand  in  relation  of 
cause  and  effect,  at  any  rate  during  intra-uterine  life. 
The  only  structural  changes  are  those  due  to  an-ested 
development  and  growth ;  there  is  nothing  of  an 
inflammatory  nature. 


270  Surgical  Pathology.       [Chap,  xlvii. 

Intra-uterine  pressure  may  explain  certain  irregular 
defects,  but  not  those  of  constant  and  definite  type. 

(2)  Paralysis  and  contraction  of  muscles. — The 
theory  of  antagonistic  contractions  holds  good  in  but 
a  limited  number  of  cases.  (We  refer  to  the  physio- 
logical contraction,  and  not  the  atrophic  shrinking 
from  forced  rest  in  unnatural  position.)  After  disease 
of  the  hip  joint,  especially  if  complicated  with  disloca- 
tion on  to  the  dorsum  ilii,  the  heel  is  drawn  up 
(talipes  equinus)  to  compensate  for  the  shortening  of 
the  limb  and  tilting  of  the  pelvis.  In  this  instance 
there  is  both  dynamic  and  static  contraction  of  the 
calf  muscles. 

In  infantile  paralysis  certain  groups  of  muscles 
often  remain  permanently  pa,ralysed  or  weak,  but  the 
opponents  do  not  drag  the  foot  in  the  opposite  direc- 
tion ;  the  position  assumed  is  that  caused  by  the 
weight  of  the  foot,  and  any  accidental  pressure  that 
may  bear  upon  it. 

Both  in  this  and  the  congenital  forms  of  club-foot 
the  deformity  is  afterwards  increased  by  misdirected 
pressure,  as  when  the  patient  comes  to  walk  upon 
the  outer  part  of  the  dorsum  in  the  latter  case,  or 
drags  the  limb  after  him  in  the  former. 

The  position  taken  by  the  hand  and  fore-arm  in 
injury  of  the  musculo-spiral  nerve  also  tells  strongly 
against  the  theory  of  muscular  antagonism.  Unless 
the  patient  voluntarily  uses  the  flexor  muscles,  the 
limb  hangs  in  a  state  of  rest,  slight  flexion  and  semi- 
pronation ;  and  further,  instead  of  the  flexors  con- 
tracting to  their  usual  extent,  the  grasping  power  of 
the  hand  is  greatly  diminished  from  want  of  the  sense 
of  resistance  by  the  extensors,  so  that  at  the  first 
one  might  think  there  was  some  actual  loss  of  power 
in  the  flexors.  The  full  efiect  of  the  extensor-paralysis 
is  brought  out  by  placing  the  upper  arm  in  the 
horizontal  position,  and  the  fore-arm  in  that  of  flexion; 


Chap.  XLVIL]  On  DEFORMITIES.  27 1 

then  it  is  seen  that  extension  of  the  elbow,  wrist,  and 
fingers  is  impossible. 

Again,  if  the  tendo  Achillis  be  divided,  say,  for 
overcoming  the  contraction  of  the  calf  muscles  in 
oblique  fracture  of  the  tibia,  the  foot  remains  some- 
what extended,  whereas  on  the  theory  of  antagonistic 
contraction  it  ought  to  become  flexed  (Volkmann). 

Physiological  contraction  of  the  muscles  alone, 
whether  arising  from  central  or  peripheral  irritation 
of  the  nerves,  is  rarely  continued  long  enough  to 
cause  permanent  deformity.  It  is  seen  in  the  "late 
rigidity  "  of  the  muscles  following  gross  lesions  of  the 
brain ;  but  here,  too,  the  muscles  undergo  interstitial 
atrophic  shortening  as  well. 

(3)  Cicatricial  and  atrophic  shortening  of  the 
muscles  and  tendons. 

The  contraction  of  inflammatory  lymph  sometimes 
causes  deformity  of  the  joints,  e.g.^  the  thigh  may  be 
left  permanently  flexed  as  the  result  of  psoitis.  I 
have  known  talipes  equinus  follow  deep  -  seated 
phlebitis  in  the  calf  of  the  leg. 

If  a  joint,  e.^.,  the  knee  or  hip,  be  allowed  to 
remain  flexed  for  a  long  time,  the  muscles  and  liga- 
ments will  shorten  up  to  the  distance  between  their 
attachments  by  a  process  of  interstitial  absorption. 
In  Pott's  fracture  one  takes  care  to  place  the  foot  at 
a  right  angle  with  the  leg  before  putting  on  a  plaster 
casing.  If  this  be  neglected,  some  difficulty  will  be 
afterwards  experienced  in  overcoming  the  resistance 
of  the  shortened  tendo  Achillis. 

From  what  has  been  said  it  will  be  gathei-ed  that 
the  chief  causes  of  deformity  lie  outside  the  joints. 
In  curvature  of  the  spine  a  softened  state  of  the  bones 
and  intervertebral  discs  greatly  aids,  and  in  fact  may 
be  the  chief  cause  of,  the  permanent  alteration  in 
shape. 


272 


CHAPTER  XLVIII. 

CURVATURE     OF     THE     SPINE. 

The  nature  of  the  curvature  depends  (1)  upon  tlio 
disease  wliich  causes  it ;  (2)  upon  the  distribution  of 
the  morbid  process,  whether  it  extends  through  the 
entire  length  of  the  cohimn,  or  is  limited  to  a  certain 
region  or  part ;  (3)  upon  the  condition  of  the  support- 
ing structures,  muscles,  and  ligaments ;  (4)  upon  any 
extrinsic  pressure  or  traction  brought  to  bear  upon 
the  spine  ;  e.g.,  in  disease  of  the  hip  joint  the  lumbar 
curve  is  exaggerated,  together  with  a  certain  amount 
of  rotation.  Unilateral  pleurisy  may  alter  the  natural 
curves,  either  during  the  effusion  stage,  or  when  tjiis 
has  passed  away  and  given  place  to  retraction  of  the 
same  side  of  the  chest  wall. 

Curvature  in  one  region,  such  as  that  which 
follows  Pott's  disease,  so  alters  the  position  of  the 
centre  of  gravity  that  unless  some  means  of  compensa- 
tion were  provided  the  body  would  be  in  a  state  of 
unstable  equilibrium.  The  effect  of  kyphosis  in  the 
dorsal  spine  is  counteracted  by  secondary  lordosis  in 
the  lumbar. 

Diseases  causing:  curvature.  —  1.  Certain 
congenital  defects.  The  lateral  portions  of  the  ver- 
tebrse  may  be  imperfectly  formed  with  or  without 
coincidental  defect  in  the  ribs.  The  writer  once  saw 
a  case  in  a  girl  aged  about  ten  years,  in  which  there 
was  a  firm  nodule  over  the  lower  dorsal  spine, 
apparently  a  cured  spina  bifida.  Opposite  this,  two 
or  three  of  the  ribs  on  one  side  were  fused  into  a  solid 
plate. '   There  was  lateral  curvature  of  the  spine. 

2.   Caries  {q.v.) 


Chap.  XLViii.]   Curvature  of  the  Spine. 


273 


3.  Kickets  {q.v.), 

4.  Osteomalacia  (q-v.). 

5.  In  aneurism^  of  the  descending  thoracic,  or  ab- 
dominal aorta,  the  bodies  and  contiguous  parts  of  the 
neural  arches  of  the  vertebrae  may  be  absorbed,  and 


Fig.  40. — Fracture  of  the  Spine. 
a,  Wedge-sbaped  mass,  forming  double-inclined  plane.  Which  has  been  driven 
backward  upon  the  cord,  c ;  6,  detritus  of  the  anterior  portion  of  the  bodies 
of  two  vertebrae. 


this  may  lead  to  projection  with  lateral  deviation  of 
the  spine. 

6.  Chronic  rheiimatis'in  sometimes  affects  the  ver- 
tebral column.  In  these  cases  the  anterior  common 
ligament  is  usually  ossified,  and  the  vertebrae  anchy- 
losed.  The  spine  is  generally  thrown  into  one  uniform 
dorsal  curve,  and  there  are  compensatory  curves  in 
the  lumbar  and  cervical  regions. 

7.  Fracture  of  the  bodies  of  the  vertebrae  (Fig.  40). 


'274  Surgical  Pathology.        [Chap.  xlix. 

The  history  of  an  injury  and  the  concomitant  signs  and 
symptoms  suflSce  to  make  the  diagnosis  easy,  although 
a  long  time  may  have  elapsed  since  repair  took  place. 
8.  One  of  the  most  important  forms  is  that  known 
as  "  lateral  curvatwreT  It  is  doubtful  where  the 
fault  lies  in  the  first  instance.  Billroth  believes  that 
the  primary  cause  is  a  weakness  -of  the  back  muscles, 
and  that  the  ligaments  and  discs  are  soft  and  yielding, 
and  the  bones  affected  with  a  ''mild  form  of  rachitis." 
It  is  most  common  in  girls  about  the  age  of  puberty, 
and  in  those  compelled  to  sit  or  stand  for  a  long  time 
in  a  constrained  position.  This  causes  a  sense  of 
fatigue,  and  to  gain  relief  th^  spine  is  supported  un- 
equally, e.g.^  by  the  hand  against  the  object  on  which 
the  patient  is  sitting.  This  gives  the  initial  curve, 
which  soon  becomes  exaggerated  and  permanent.  If 
the  dorsal  curve  is  to  the  right^  there  is  compensatory 
lumbar  curve  to  the  left ;  compensatory,  but  not 
secondary,  for  in  all  probability  both  arise  together. 
When  the  lateral  curve  is  at  all  marked,  a  certain 
amount  of  rotation  or  twisting  is  also  observed  After 
a  time  the  bodies  of  the  vertebrae  become  unequal  in 
depth  on  the  two  sides,  and  sometimes  they  are  more 
or  less  anchylosed  by  new  bone.  I  have  known  the 
lumbar  vertebrse  to  be  a  third  of  an  inch  deeper  on 
one  side  than  the  other. 


CHAPTER    XLIX. 

DEFORMITIES    OP    THE    FOOT,    KNEE,    AND    HIP. 

Talipes  eqiiino-variis  is  the  most  common 
variety  of  congenital  deformity  of  the  foot.  The 
extension   is   due  to  a  contracted  state  of  the  tendo 


Chap  XLix.]  Talipes.  275 

Achillis  ;  the  inversion  to  a  like  defect  in  the  tibiales, 
especially  the  tibialis  posticus.  The  ball  of  the  great 
toe  is  aj^proximatecl  to  the  heel,  and  the  plantar  fascia 
is  shortened.  The  dorsum  and  outer  border  of  the 
foot  are  more  convex  than  natural.  The  tarsal  bones 
are  more  or  less  wedge-shaped,  the  base  of  the  wedge 
being  outwards.  In  well-marked  cases  the  astragalus 
is  partially  dislocated  outwards.  After  the  patient  has 
learned  to  walk,  the  deformity  increases,  for  the  pres- 
sure exerted  by  the  weight  of  the  body  is  misdirected. 
Being  greater  on  the  inner  portions  of  the  tarsal  bones 
than  on  the  outer,  growth  is  checked  in  the  former 
direction  ;  and  as  the  movement  of  the  bones  one 
upon  the  other  is  greatly  restricted,  they  inay  become 
anchylosed.  The  liability  to  this  is  increased  by  the 
irritation  caused  by  walking  and  standing  on  parts 
ill-adapted  to  receive  and  transmit  pressure.  For  the 
same  reason  callosities  and  subcutaneous  bursse  are 
developed.  The  fore  9,nd  n]iddle  parts  of  the  foot  are 
stunted  in  growth. 

Talipes  eqiiiniis  is  more  often  the  result  o| 
injury  or  acquired  disease  than  a  congenital  deformity, 
In  the  case  from  which  Fig.  8  was  taken,  it  followed 
cicatrisation  of  a  gun-shot  wound  of  the  tendo  Achillis. 

There  is  shorteninsj  of  the  calf  muscles  or  the  heel 
tendo^.  A  dense  callosity  forms  over  the  balls  of  the 
toes.  The  toes  themselves  are  pressed  and  drawn 
upwards,  so  that  they  become  partially  dislocated  on 
to  the  heads  of  the  metatarsal  bones. 

Talipes  valgxis  et  calcaneo-valgxis. — In  the 
former  the  peroneal  tendons  are  shortened  and  the 
tibials  elongated.  When  the  heel  is  depressed  (cal- 
caneus) the  extensors  are  contracted  and  the  tendo 
Achillis  leng-thened. 

Pes  plaiins  et  plano-valg^is.  —  These  de- 
formities are  usually  met  with  in  youth  and  early 
adult  life.     They  are  comparable  to  genu  valgum  and 


276  Surgical  Pathology.        [Chap.  xlix. 

lateral  curvature  of  the  spine.  As  tlie  consequence  of 
long  standing,  the  muscles  and  ligaments  give  way. 
Both  arches  of  the  foot,  antero-posterior  and  intero- 
external,  are  lowered.  The  ligaments  failing  to 
support  the  strain  upon  them,  the  muscles  are  in  a 
constant  state  of  tension,  and  this  causes  the  symptom 
complained  of,  viz.,  aching  pain,  referred  at  one  time 
to  the  instep  or  sole  of  the  foot,  at  another  to  the 
muscles  of  the  leg. 

Oeiiu  valgTim  is  the  result  of  rickets  in  children, 
or  continued  strain  upon  the  knees  in  youths  and 
young  adults,  and  more  rarely  in  later  life.  The 
internal  lateral  ligament  is  stretched.  The  external 
and  the  biceps  tendon  shortened.  The  inner  condyle 
of  the  femur  is  said  to  be  hypertrophied.  What 
really  happens  is  this  :  if  the  bending  of  the  knee 
occurs  after  the  bones  are  fully  grown,  the  external 
condyle  atrophies  from  pressure ;  if  it  comes  on 
during  childhood  or  youth,  there  is  unequal  growth 
of  the  two  condyles  :  that  of  the  outer  is  checked  by 
the  weight  of  the  body  transmitted  through  it,  whilst 
that  of  the  inner  is  unrestrained.  In  rickets  there  is 
sometimes  knock-knee  of  one  limb  and  bandy-leg  of 
the  other,  the  convexity  of  the  former  fitting  into  the 
concavity  of  the  latter.  This  is  due  to  the  way  in 
which  the  child  is  carried  by  the  nurse. 

Bandy-leg'  occurs  in  rickets.  The  pathology  is 
the  same  as  in  genu  valgum.  The  anatomy  is  simply 
reversed. 

It  is  simulated  by  outward  curvature  of  the 
femur. 

Deformities  of  the  liip  consist  of  congenital 
dorsal  dislocation,  and  malposition  from  contraction 
of  the  muscles,  ligaments,  and  fasciae. 

Deformity  from  infantile  paralysis. — As 
before  said,  the  foot,  when  in  a  state  of  rest,  is 
partially  extended  and  slightlj  inverted.    The  position 


Chap.  XLix.]       Infantile  Paralysis.  277 

is  assumed  and  maintained  by  the  weight  of  the  foot 
and  the  tone  of  the  muscles. 

In  iofantile  paralysis  of  marked  degree  the  muscles 
are  not  only  placed  beyond  the  influence  of  the  will, 
but  there  is"^a  want  of  tone  as  well.  The  paralysis  is 
rarely  so  extensive  as  to  involve  all  the  muscles  of 
a  limb ;  usually  only  a  group  of  muscles  or  individual 
ones  are  affected.  ISTow  although  paralysis  of  one  set 
does  not  at  once  cause  displacement  by  the  con- 
traction of  the  antagonists,  still,  when  the  patient 
uses  the  foot,  the  want  of  power  of  support  in  the 
direction  of  the  j^aralysed  muscles  must  greatly  in- 
fluence the  development  of  the  deformity.  This, 
however,  is  chiefly  eff'ected  by  other  agencies.  The 
foot  being  allowed  to  remain  in  the  position  assigned 
to  it  by  its  own  weight,  the  soft  structures  (muscles, 
tendons,  ligaments,  and  fascise)  undergo  an  atrophic 
shortening,  which  serves  to  perpetuate  the  malposition. 
And,  again,  the  weight  of  the  body  thrown  upon 
the  foot  thus  displaced  aggravates  the  deformity  or 
alters  its  direction.  In  extreme  cases,  the  affected 
foot  is  dragged  after  the  other  ;  and  the  inner  border 
and  fore  part  coming  in  contact  with  the  ground,  the 
extension  is  increased,  whilst  any  original  inversion  is 
removed,  or  even  replaced  by  eversion.  If,  on  the 
other  hand,  the  patient  is  able  to  use  the  limb  fairly 
well,  the  equinus  is  still  well  marked,  for  the  limb 
is  always  more  or  less  stunted  in  growth,  so  that  the 
sole  of  the  foot  cannot  properly  be  brought  to  the 
ground  in  progTession.  The  tendency  is  also  to  roll 
in  or  out  according  as  the  want  of  support  is  greater 
on  one  side  or  the  other. 

Thus  the  deformity  from  infantile  paralysis  is  not 
a  definite  one.  In  depends  upon  several  factors :  the 
weight  of  the  foot,  loss  of  tone  in  the  paretic  muscles, 
secondary  contractions  and  elongations  of  the  muscles 
and  ligaments,  and  the  direction  of  pressure. 


278  Surgical  Pathology.  [Chap.  l. 

Infantile  paralysis  is  Lelieved  to  be  due  to  atrophy 
of  the  motor  ganglion  cells  in  the  anterior  cornua  of  the 
grey  matter  of  the  spinal  cord,  though  it  may  be  that 
the  nerve  endings  in  the  muscles  are  primarily  at  fault. 
Unless  the  power  of  the  paralysed  muscles  is  restored 
within  a  short  time  (say  a  month  or  two)  it  will 
probably  never  be  regained.  Subsequent  improvement 
in  the  contractility  is  then  chiefly  confined  to  fibres 
that  have  wasted  from  simple  disuse. 

When  the  paralysis  is  thoroughly  established, 
the  treatment  consists  of  measures  taken  with  a  view 
of  improving  the  nutrition  of  the  limb  in  general, 
and  the  muscles  in  particular,  such  as  electricity  and 
massage  ;  and  in  preventing  and  correcting  deformities 
by  the  use  of  surgical  apparatus. 

Otlier  deformities  arise  from  congenital  absence 
or  contraction  of  muscles  ;  e.g.^  the  sterno-mastoid, 
arrested  development  of  a  bone  or  limb,  persistence  of 
a  branchial  cleft  in  the  neck,  etc. 

There  remains  for  description  the  pathology  of 
spina  bifida,  cerebral  meningocele  and  encephalocele, 
cleft  palate,  and  extroversion  of  the  bladder. 


CHAPTER    L. 

SPINA       BIFIDA. 

Spina  bifida  is  a  congenital  deformity  that  owes 
its  origin  to  arrested  development  of  the  neural  arches 
of  the  vertebree. 

The  absence  of  coalescence  of  the  laminae  allows 
the  spinal  membranes  to  protrude,  and  carry  with 
them  the  cord  or  nerve  roots ;  and  in  the  case  of 
the  sacral  spine  the  beginnings  of  the  nerve  trunks. 


Chap.  L.]  Spina  Bifida.  279 

The  tiimoiir  is  situated  in  the  mid-line  of  the 
back.  It  is  usually  globular  in  shape,  and  about  the 
size  of  an  orange.  When  obloug,  the  long  axis  is 
parallel  to  the  spinal  column.  The  extent  in  this  direc- 
tion depends  upon  the  number  of  vertebrae  involved. 

The  lumbo-sacral  region  is  the  most  common  seat 
of  the  affection,  i.e.,  where  the  laminse  of  the  neural 
arches  are  naturally  late  in  completion ;  but  no 
part  of  the  spine  is  exempt ;  in  fact,  the  entire 
neural  canal  may  remain  open. 

It  is  not  certain  whether  the  arrest  in  development 
is  always  primary,  or  whether,  in  some  instances  at 
least,  it  may  not  be  due  to  the  pressure  of  fluid  ac- 
cumulated in  the  canal.  The  occasional  coincidence  of 
other  congenital  defects  {e.g.,  talipes)  seems  to  tell  in 
favour  of  the  former  hypothesis. 

The  \Fall  of  the  sac  is  composed  of  the  in- 
teguments, the  dura  mater  and  parietal  layer  of  the 
arachnoid,  and  generally  also  the  visceral  layer  of 
that  "  membrane,''  so  that  the  jiiiid  is  contained  in  a 
cavity  continuous  with  the  subarachnoid,  or  "internal 
arachnoid,"  space.  More  rarely  the  sac  is  lined  by 
the  parietal  layer  of  the  arachnoid,  and  the  fluid 
contained  between  the  parietal  and  visceral  portions. 
In  each  case  the  condition  is  known  as  "hydro- 
meningocele." 

In  other  cases  the  central  canal  of  the  cord  is 
dilated,  and  the  cord  itself,  or  what  remains  of  it, 
spread  out  over  the  fluid  (hydro-myelocele),  which  in 
this  instance,  and  also  in  internal  hydro-meningocele, 
presents  all  the  characters  of  cerebro-spinal  fluid. 

The  sac  is  unilocular,  or  divided  into  compart- 
ments by  partial  dissepiments.  The  skin  over  the 
tumour  is  sometimes  very  thin,  and  the  laminae 
forming  the  sac  fused  into  a  semi-translucent 
membrane,  sometimes  of  such  tenuity  as  to  rupture 
spontaneously. 


28o 


Surgical  Pathology. 


[Chap.  L. 


Now  and  again  a  central  dimple  can  be  seen  in 
the  swelling  marking  the  attachment  of  the  spinal 
cord  to  the  inner  surface  of  the  sac.     It  is  clear  that 


a 


Fig.  41. — LumlDO-sacral  Spina  Bifida,  from  the  Body  of  a  Subject 
aged  29. 

A  portion  of  the  sac  has  heen  removed  to  expose  the  nerves,  6,  which,  after 
running  for  a  short  distance  iu  the  cavity,  can  he  seen  to  enter  its  walls ; 
o,  bodies  of  vertebriB  in  antero-posterior  section.  There  is  lateral  curvature 
and  rotation  of  the  spine.    (One-third  natural  size.) 


this,  and  the  existence  of  hydro-myelocele,  can  only  be 
met  with  in  the  dorsal,  cervical,  and  lumbar  regions, 
and  rarely  in  the  lower  part  of  the  last-mentioned 
situation;  for,  before  the  tumour  has  reached  any 
size,    the   cord   has   already    receded   in   an   upward 


Chap.  L.]  Spina  Bifida.  281 

direction,  as  tlie  result  of  its  growth  being  out- 
stripped by  that  of  the  spine. 

The  cereTbro-spinal  fluid  found  in  the  sac  is 
usually  quite  clear  and  colourless  j  but  it  may  be 
blood-stained  from  capillary  rupture,  or  slightly  turbid 
from  eflpQsion  of  inflammatory  lymph  and  cells. 

Wilks  and  Moxon  describe  the  process  of  secretion 
as  an  "irritative  dropsy." 

Relation  of  tlie  nerve-roots,  nerves,  and 
spinal  cord  to  the  sac. — When  the  central  canal 
is  dilated,  the  cord  may  be  spread  out  over  the  inner 
surface  of  the  sac,  or  it  may  have  entirely  atrophied 
from  the  centrifugal  pressure. 

The  cords  of  the  cauda  equina  (nerve-roots) 
usually  course  through  the  centre  of  the  sac,  and 
"those  which  would  naturally  correspond  to  the 
vertebrae  implicated  in  the  tumour  pass  through  the 
membranes  to  their  distribution,  while  the  lower  ones 
return  into  the  spinal  canal "  (Holmes) .  The  nerve- 
roots  may  end  in  the  wall  of  the  sac,  or  they  may  be 
altogether  absent.  In  the  case  before  alluded  to 
(page  269)  there  was  no  trace  of  the  spinal  cord,  or  of 
the  roots  of  the  nerves,  in  the  neural  canal. 

Associated  deformities. — The  most  common 
is  chronic  hydrocephalus ;  next  to  this  some  variety  of 
club-foot. 

Pressure  applied  to  the  hydrocephalic  skull  will 
sometimes  increase  the  tension  of  the  sac  of  the 
spina  bifida ;  but  frequently  the  fluid  collected  in  the 
ventricles  is  confined  there  by  obliteration  of  the 
Sylvian  aqueduct,  or  closure  of  the  communication 
between  the  fourth  ventricle  and  the  subarachnoid 
space  (Hilton).  The  latter  condition  I  found  in  a 
case  of  lumbar  spina  bifida  and  chronic  hydroce- 
phalus. 


252 


CHAPTER  LI. 

CEREBRAL  MENINGOCELE  AND  MENINGO-ENCEPHALOCELE. 

Cerebral  meningocele  and  meningo-encephalocele  are 
the  analogues  of  spinal  hydro-meningocele  and  hydro- 
myelocele  ;  i.e.,  the  protrusion  is  either  of  the  cere- 
bral membranes  alone,  or  of  these  together  with  the 
brain  substance  surrounding  the  ventricles.  The 
opening  in  the  skull  is  most  commonly  found  in  the 
occipital  bone ;  it  has  been  seen  at  the  root  of  the 
nose,  and  the  tumour  mistaken  for  a  nsevus.  More 
rarely  the  parietal  and  squamous  bones  are  perforated, 
and,  still  more  rarely,  the  base  of  the  skull.  In  the 
latter  case  one  would  expect,  on  developmental 
grounds,  to  find  the  floor  of  the  pituitary  fossa 
absent. 

The  cranial  sutures  are  generally  spared. 


CHAPTER  LII. 

CLEFT    PALATE    AND    HARE-LIP. 

In  the  human  being,  that  portion  of  the  upper 
jaw  which  carries  the  incisor  teeth  never  remains 
separate  from  the  rest,  except  as  the  result  of  arrested 
development  and  growth  ;  but  in  the  lower  mammals, 
e.g.,  the  dog,  it  exists  throughout  life  as  two  distinct 
bones,  called  "intermaxillary"  or  "  prem axillary." 
And,  even  in  congenital  malformation  of  the  palate 
and  alveolar  arch,  the  fissure  never  runs  straight 
through   in   the  middle  line,   but  diverges  near   the 


Chap.  LiL]       Cleft  Palate  and  Hare  Lip.       283 

anterior  part  of  the  jaw,  and  passes  out  between  the 
portions  of  bone  that  carry  respectively  the  incisor 
and  canine  teeth.  That  is  to  say,  although  the 
osseous  continuity  between  the  maxillae  and  pre- 
maxillse  may  be  wanting,  the  premaxillse  themselves 
are  always  united  into  one  piece  of  bone.  In  early 
fcetal  life  there  is  one  large  cavity,  called  the  "  naso- 
bucco-pharyngeal ; "  this  is  subsequently  partitioned 
off  into  four  communicating  compartments,  the 
mouth,  pharynx,  and  nasal  fossae,  by  the  growth  of 
two  septa,  the  hard  and  soft  palate  and  the  septum 
nasi. 

The  roof  of  the  mouth  is  completed  by  the  union 
in  the  middle  line  of  two  laminae  advancing  from  the 
sides  of  upper  jaw  and  palate  bones,  and  the  un- 
ossified  structures  behind.  If  this  union  fails  to  take 
place,  cleft  palate  is  the  result. 

It  may  consist  merely  of  a  bifid  u^oila,  or  extend 
through  the  soft  palate,  or  through  the  whole  or  any 
portion  of  the  hard  palate ;  but,  as  before  said,  it 
never  passes  out  in  the  middle  line  in  front. 

When  the  cleft  reaches  the  posterior  part  of  the 
intermaxillary  nodule,  it  may  bifurcate,  and  the  two 
limbs  of  the  fissure  isolate  that  piece  of  the  jaw. 
This  is  known  as  "double-cleft  palate."  Single  or 
double,  when  complete,  it  is  almost  invariably  con- 
tinuous with  a  split  in  the  upper  lip. 

Cleft  of  the  soft  palate  often  exists  alone ;  so  also 
hare-lip ;  but  cleft  of  the  hard  palate  is  rarely  found 
without  the  velum  being  implicated. 

As  the  roof  of  the  mouth  is  wanting  in  the 
middle  line,  it  is  clear  that  the  septum  nasi,  unless  its 
lower  border  remains  free,  must  deviate  to  one  side  or 
the  other,  in  order  to  join  the  hard  palate  j  and  this 
is  what  usually  happens. 

When  the  cleft  in  the  alveolar  arch  is  double,  the 
intermaxillary  nodule  can  be  swayed  backwards  and 


284  Surgical  Pathology.  [Chap.  liii. 

forwards,  and  the  rudiments  of  the  incisor  teeth 
which  it  contains  do  not,  as  a  rule,  develop  to  the 
normal  extent.  This  is  one  reason  why,  in  operations 
for  the  cure  of  the  deformity,  the  surgeon  often  elects 
to  remove  the  piece  of  bone. 

In  hare-lijy  the  fissure  is  to  the  side  of  the  middle 
line  j  in  the  hare  it  is  situated  in  the  centre  of  the 
lip.  It  may  be  partial,  or  extend  into  the  nostril.  In 
the  latter  case,  the  ala  nasi  is  flattened,  for  the 
muscles  draw  it  and  the  corresponding  part  of  the 
lip  outwards. 


CHAPTER   LIII. 

EXTROVERSION    OF    THE    BLADDER ECTOPIA   VESICA 

HYPOSPADIAS. 

Here  the  anterior  part  of  the  abdominal  wall  and 
the  anterior  wall  of  the  bladder  are  wanting.  At 
birth  they  are  usually  present  in  the  form  of  a  thin 
membrane,  which  afterwards  dries  up  and  is  cast  off 
as  a  slough  by  the  development  of  a  ring  of  granula- 
tions at  its  periphery.  When  the  defect  reaches  its 
highest  grade,  the  proximal  part  of  the  umbilical  cord, 
instead  of  being  inserted  as  usual  into  the  wall  of  the 
abdomen,  is  spread  out  as  a  membranous  lamina  con- 
tinuous with  the  attenuated  structures  below,  and, 
after  ligature,  separates  with  them. 

The  posterior  wall  of  the  bladder  is  thus  exposed, 
and,  having  lost  its  support  in  front,  is  thrust  for- 
wards by  the  underlying  viscera,  so  that,  instead  of  a 
cavity,  there  is  a  bright-red  elevation  covered  with 
mucous  membrane. 

The  symphysis  pubis,  too,  is  often  imperfectly  deve- 
loped, the  pubic  bones  being  united  by  a  ligamentous 


Chap.  Liv.j  Hypospadias.  285 

band,  and  more  or  less  everted  by  tlie  resultant  of 
two  forces  exerted  by  the  adductors  of  the  thigh  and 
the  oblique  muscles  of  the  abdomen. 

The  urethra  is  wanting.  There  is  a  groove 
on  the  dorsal  surface  of  the  penis,  commencing  at 
the  lower  part  of  the  unnatural  opening  in  the 
bladder.  When  tliis  opening  is  confined  to  a  small 
aperture  above  the  pubes,  the  condition  is  known  as 
epis-padias. 

In  ectopia  vesicae  the  urine  constantly  escapes 
from  the  exposed  orifices  of  the  ureters,  and,  coming 
in  contact  with  the  skin  of  the  abdomen,  causes  con- 
siderable irritation. 

The  transition  from  skin  to  mucous  membrane  is 
imperceptible. 

Hypospadias  is  due  to  imperfect  development 
and  union  of  the  lateral  lappets  that  go  to  form  the 
normal  urethra.  It  may  extend  the  whole  length  of 
the  penis,  but  it  is  generally  confined  within  a  short 
distance  from  the  end  of  the  gians.  In  the  former 
case  the  scrotum  may  be  cleft.  Instead  of  the 
urethra  being  wanting  in  its  anterior  part,  as  described 
above,  there  may  be  a  small  opening  at  the  peno- 
scrotal angle  or  in  the  perinaeum. 


CHAPTER  LIY. 

FATTY   DEGENERATION    OF    ARTERIES,    AND    ARTERITIS, 

Many  terms  more  or  less  misleading  have  been 
used  in  the  description  of  arterial  .pathology;  e.g.^ 
atheroma^  which  is  merely  the  consequence  of  prece- 
dent inflammation,  and  degeneration,  is  often  used  to 
indicate  the  substantive  disease.      In  this  work  the 


286    •  Surgical  Pathology.  [Chap.  liv. 

morbid  processes  and  tlieir  results  will  be  described  as 
they  occur  separately  or  in  combination. 

Fatty  degeneratioii  is  met  with  under  two 
conditions  :  (1)  As  a  primary  and  solitary  change;  (2) 
as  the  sequel  of  inflammation. 

(1)  Primary  fatty  degeneration  is  best  seen  as  it 
affects  the  endothelial  and  subendothelial  layers  of 
the  internal  coat.  It  is  most  common  in  the  first  part 
of  the  aorta,  and  although  it  increases  in  frequency  as 
age  advances,  it  is  by  no  means  rare  in  early  life.  It 
causes  small,  slightly  elevated  yellowish  white  patches. 
The  fat  granules  are  for  the  most  part  arranged  in 
groups,  still  retaining  the  outline  of  the  stellate  endo- 
thelial cells  (Fig.  4a).  The  tissue  beneath  may  be  quite 
healthy;  so  that  these  cases  have  no  clinical  significance. 

The  fat  granules  are  absorbed  or  swept  off  by 
the  blood  stream,  and  new  cells  replace  the  old  ones. 

But  the  degeneration  may  be  more  wide-spread  in 
the  coats  of  the  vessel.  Tliis  is  very  constant  in 
senile  decay.  Hounded  and  bead-like  collections  are 
seen  in  the  middle  coat,  following  the  course  of  the 
elastic  laminae  and  muscular  fibre-cells. 

(2)  As  the  sequel  of  inflammation,  fat  molecules 
are  never  absent.  The  greater  part  of  the  contents  of 
"  atheromatous  abscesses  "  is  composed  of  them. 

Acute  endarteritis. — Diffuse  suppm-ative  or 
phlegmonous  arteritis  is  unknown.  The  disease  in 
question  affects  chiefly  the  large  arteries,  especially 
the  aorta.  In  some  cases  there  is  a  history  of  syphilis, 
but  in  most  the  cause  is  obscure. 

The  inner  surface  of  the  vessel  has  an  irreg-ular 
gTeyish  semi-translucent  appearance,  as  if  melted 
gelatine  had  been  sprinkled  upon  it,  and  then  set. 
Some  patches  are  yellowish  from  fatty  change.  Calci- 
fication is  rare.  When  cut  into,  the  inflamed  spots  are 
found  to  be  elastic  and  gelatinous-looking.  The 
swollen    intima    may    be    many    times    thicker    than 


Chap.  LI  v.]  Atheroma.  287 

natural.  The  middle  coat  is  more  or  less  involved, 
but  never  to  the  extent  as  in  chronic  arteritis . 
(atheroma).  Under  the  microscope  the  diseased  struc- 
ture is  found  to  be  infiltrated  with  small  cells,  which  < 
lie  parallel  to  the  laminae.  The  cells  are  partly  derived 
from  the  vasa-vasorum,  partly  from  segmentation  of 
the  subendothelial  corpuscles.     In  old  cases  the  cells 


~,^--^ 


Fig  42. — Sectioa  of  the  Tumca  Interna  of  the  Aorta,  in  a  case  of 
Acute  Endarteritis. 

This  section,  made  after  desiccation  of  tbe  artery,  shows  the  proliferation  of  the 
elements  of  the  internal  membrane.    (Afte)-  Comil  and  Ranvier.) 

may  almost  -entirely  have  disappeared,  leaving  a  dense 
cartilaginiform  homogeneous  substance,  and  a  few  fat 
molecules. 

The  most  pronounced  €ase  I  have  seen  was  in  a 
subject  Vkdth  aneurism  of  the  aorta  and  both -popliteal 
and  the  right  femoral  arteries.  The  entire  aorta  was 
studded  with  hard,  smooth,  grey  elevations,  from  the 
size  of  a  pin's  head  to  a  pea. 

Chronic  endarteritis..— Atheroma.  This 
disease  is  said  to  begin  in  the  deeper  portion  of  the 
internal  coat.  Small  cells  accumulate  in  the  midst  of 
a  homogeneous  or  granular  matrix  of  exudation  matter, 
and  softened  coat  of  the  vessel.  This  goes  on  until 
there  is  bulging  into  the  vessel,  which  here  appears  of 
a  dull,  yellowish-white  colour.  Should  the  inflamma- 
tion stop  at  this  stage,  the  products  of  it  will  be 
partially  absorbed  subsequent  to  fatty  degeneration, 
and  the  remaining  portion  of  the  intima  will  come  m. 


288  Surgical  Pathology.  [Chap.  liv. 

contact  with  the  middle  coat ;  or,  if  the  latter  has  been 
destroyed,  the  internal  and  external  coats  will  blend, 
forming  together  a  slightly  depressed  fibrous  cicatrix. 
But,  meanwhile,  lime-salts  are  frequently  deposited, 
and  then  a  brittle  calcareous  plate  serves  as  a  mark  of 
the  previous  arteritis.  During  the  slow  progress  of 
the  inflammation  the  cells  are  transformed  into  fat, 
and  this  again  into  its  chemical  derivatives ;  so  that  a 
so-called  athero'matous  abscess  is  filled  with  degenerating 
cells,  granular  debris,  carbonate  of  lime,  and  crystals 
of  cholesterine  and  the  fatty  acids,  and,  perhaps, 
hsematoidin  crystals.  If  the  pellicle,  which  bounds 
the  atheromatous  focus  next  the  lumen  of  the  vessel, 
gives  way,  the  contents  of  the  cavity  are  washed  out 
by  the  blood  stream,  and  the  remaining  excavation  is 
termed  an  atheromatous  ulcer.  The  base  of  the  "ulcer" 
usually  calcifies,  or  becomes  fibrous.  The  calcareous 
plates  above  mentioned  sometimes  split  away  at  the 
margin,  and  pigment  is  deposited  beneath  them  from 
the  blood  undergoing  coagulation  as  it  trickles  through 
the  fissures.  They  also  act  as  foreign  bodies,  and 
cause  extensive  thrombosis.  They  may  be  detached, 
and  give  rise  to  embolism. 

Arteritis  deformans. — In  old  people,  chronic 
inflammatory  and  degenerative  changes  are  widely 
spread.  Homogeneous  thickening  of  the  internal  coat, 
atheromatous  patches,  calcified  plates  in  the  large 
arteries,  and  calcified  rings  in  the  small  and  medium- 
sized  ones,  may  all  be  found  in  the  same  subject.  On 
the  whole  these  senile  arteries  are  dilated,  but  the 
inner  coat  may  be  so  thickened  as  to  cause  serious 
obstruction  to  the  blood  current,  and  cause  thrombosis 
and  gangrene.  Like  varicose  veins,  the  arteries  are 
elongated,  so  that  they  are  thrown  into  permanent 
curves. 

Syphilitic  disease  of  the  arteries. 

(1)  Syphilis,  by    impairing    the   nutrition  of  the 


Chap.  Liv.]  Diseases  of  Arteries.  289 

tissues  generally,  may  lead  to  early  senile  changes — 
fatty  degeneration  and  atheroma. 

(2)  But  there  is  a  specific  syphilitic  inflammation 
of  the  arteries,  more  or  less  acute  in  its  progress.  It 
begins  in  the  internal  coat,  but  the  entire  thickness  of 
the  walls  may  be  converted  into  a  glassy  or  slightly 
fibrillated  substance  containing  small  cells.  In  the 
arteries  of  the  brain  there  is  a  good  deal  of  exuda- 
tion into  the  perivascular  sheaths  as  well,  so  that 
the  lumen  is  narrowed  from  swelling  within  and  com- 
pression without. 

It  is  one  of  the  chief  causes  of  cerebral  thrombosis. 
The  softened  state  of  the  vessels  renders  them  very 
liable  to  aneurismal  dilatation.  In  the  case  of  the 
aorta  and  other  large  arteries  the  inner  coat  is 
enormously  thickened  and  uneven. 

Atheroma  and  calcification  are  less  common  than 
in  senile  disease. 

Arterio-capillary  li1>rosis  enters  largely  into 
the  pathology  of  granular  gouty  kidney.  It  is  not 
limited  to  that  organ,  but  is  widely  distributed 
throughout  the  various  tissues  (skin,  nerve-centres, 
etc.).  The  walls  of  the  vessels  are  thickened  by  a 
hyalin-fibroid  material  (Gull  and  Sutton)  and  hyper- 
trophy of  the  middle  coat  (Johnson).  The  lumen  of 
the  vessels  is  lessened.  The  obstruction  it  causes 
induces  hypertrophy  of  the  left  ventricle  of  the  heart. 

Other  causes  of  arteritis  need  only  be  mentioned. 
They  are  chronic  alcoholism  and  rheumatism. 

Inflamiiiatioii  of  the  middle  and  external 
coats. — It  is  doubtful  if  this  occurs  as  a  primary 
disease.  The  middle  coat  may  be  destroyed  by  inflam- 
mation reaching  it  from  either  side.  The  external  is 
involved  in  like  manner,  but  it  especially  suffers  in 
periarteritis. 

Periarteritis  consists  of  an  inflammation  of  the 
external    coat   and  its  areolar  sheath.     They  rarely 

T 


290  Surgical  Pathology.  [Chap.  lv. 

escape  altogether  in  acute  and  chronic  endarteritis. 
It  has  been  shown  that  in  syphilitic  disease  of  the 
cerebral  arteiies  the  perivascular  sheaths  are  ex- 
tensively infiltrated ;  in  fact,  several  vessels  are 
occasionally  imbedded  in  a  continuous  mass  of 
exudation. 

In  thrombosis  of  the  deep  veins  the  periphlebitis 
extends  to  the  companion  arteries.  Not  only  may 
the  areolar  sheath  and  external  coat  of  an  artery  be 
softened  by  inflammation  until  bulging  takes  place,  as 
in  aneurisms  of  branches  of  the  pulmonary  arteries 
skirting  phthisical  cavities,  but  the  tension  upon  the 
vasa-vasorum  may  be  so  great  that  the  entire  thickness 
of  the  wall  of  a  large  artery  may  slough  away;  e.g.., 
the  femoral  in  spreading  perilymphatic  abscesses  of 
the  groin. 

Periarteritis,  by  causing  canalisation,  serves  as  a 
dangerous  check  upon  hsemostasis  in  wounded  vessels; 
it  prevents  contraction,  and  retraction  within  the 
sheath. 


CHAPTER   LY. 

A-ifEURISM. 

Varieties  of  alieiirism. — Aneurisms  are  either 
traumatic,  or  pathological  (spontaneous).  The  term 
traumatic  is  limited  to  those  cases  that  form  directly 
as  the  result  of  injury.  Many  pathological  aneurisms 
can  be  traced  to  some  local  strain,  but  of  such  a  degree 
that  had  the  vessel  been  healthy  it  would  not  have 
given  way. 

Dilfiise  traumatic  aneiirlsms.— Blood 
escapes  from  the  wounded  vessel  into  the  interstices 
of  the  surrounding  structures,  and  in  the  direction  of 


Chap.  Lv.]  Aneurism.  291 

least  resistance,  e.g.^  in  the  intermuscular  planes  and 
beneath  fasciae.  The  distending  force  is  too  great  to 
allow  of  an  adventitious  sac  of  inflammatory  tissue 
being  formed.  Thus  a  traiTmatic  aneurism  of  the 
popliteal  artery  may  spread  up  the  thigh,  or  the  blood 
from  a  ruptured  axillary  fill  the  arm-pit.  The  only 
treatment  likely  to  avail  is  ligature  of  the  artery  on 
each  side  of  the  wound,  or  amputation.  The  cause  is 
usually  a  stab,  or  rupture  during  the  attempt  to 
reduce  an  old  dislocation. 

Sacculated  or  circuinscribed  traumatic 
aneiu'ism. — These  are  either  simple,  or  arterio- 
venous. In  the  former  case  the  sac  is  variously 
constituted.  (1)  It  may  be  formed  by  a  yielding 
cicatrix,  after  the  wound  in  the  artery  has  closed; 
this  can  only  happen  when  the  artery  is  small,  or  the 
opening  in  it  very  minute.  (2)  It  may  consist  of  a 
protrusion  of  the  internal,  or  internal  and  middle, 
coats  through  a  wound  in  the  external  (hernial 
aneurism).  (3)  It  may  be  formed  of  the  external 
coat,  the  internal  and  middle  having  been  lacerated  by 
bruising  against  a  bone.  (4)  The  sac  may  be  purely 
adventitious,  all  the  coats  having  been  divided  \  in 
such  cases  the  blood  escapes  very  slowly ;  the 
inflammatory  induration  around  suffices  to  prevent  a 
rapid  extension  of  the  aneurism. 

Arterio-vetioiis  aneiu'ism  results  from  the 
simultaneous  wounding  of  an  artery  and  neighbouring 
vein,  e.g.^  the  brachial  and  median  basilic  in  blood- 
letting at  the  head  of  the  elbow.  If  the  inflammatory 
exudation  caused  by  the  injury  fixes  the  vessels  in 
contact,  the  blood  will  pass  directly  from  the  artery  to 
the  vein,  and  the  latter  will  become  dilated  and 
tortuous,  and  will  have  its  walls  thickened  from  the 
irritation  of  the  strain  (cineurismal  varix). 

But  the  cementing  lymph  may  yield  and  form  a 
sac  between  the  two  vessels  {varicose  aneurism).    This 


292 


Surgical  Pathology. 


[Chap.  LV. 


is  the  more  dangerous  variety,  since  the  sac  is  usually 
thin,  and  the  tension  upon  it  is  more  concentrated 
than  on  the  resilient  walls  of  vein.  The  pulsation, 
bruit,  and  thrill  are  also  stronger  than  in  aneurismal 
varix. 

Pathological  or  spoiitaiieous  aneui'tsms 
are  divided  into  true  and  false.  The  sac  of  a  true 
aneurism  is  said  to  be  formed  of  all  the  coats  of  the 
vessel,  but  on  pathological  grounds  the  distinction  is 
not  well  founded  ;  for  the  disease  of  the  vessel  ere  it 


Fig.  43.— Section  through  Femoral  Artery,  just  below  an  Aneurism. 
a.  Tunica  intima,  rugged  and  greatly  thickened. 


allows  of  dilatation  has  caused  at  least  the  middle 
coat  to  disappear.  Syphilitic  and  idiopathic  arteritis 
(atheroma)  are  the  causes  of  the  weakness  of  the 
vessel.  In  chronic  arteritis  the  deeper  layers  of  the 
internal  coat  and  the  middle  coat  are  destroyed,  so 
that  what  remains  of  the  internal  coat  is  blended 
Avith  the  external,  and  both  are  so  diseased  that  their 
natural  structure  cannot  be  made  out.  Frequently, 
also,  the  aneurism  develops  at  the  seat  of  an 
atheromatous  ulcer,  when  nothing  but  the  external 
coat  remains.  In  most  cases  the  irritation  kept  up 
causes  the  sac  to  be  thickened  by  the  interstitial 
deposit  of  lymph  and  inflammatory  condensation  of 
the  areolar  tissue  outside.      From   want   of  elasticity 


Chap.  LV.] 


Aneurism. 


293 


the  sac  continues  to  dilate  in  spite  of  its  thickness. 
But  usually  there  comes  a  time  when  the  dilatation  is 
so  rapid  that  the  sac  is  greatly  thinned,  and  finally  it 
gives  way  {imjjtured  aneurism). 

The  clot  witliiii  tUe  aiieiirism  is  more  or  less 
laminated.  The  first  formed  laminse  lie  at  the  bottom 
of  the   sac,   but   do  not   reach   its  neck,  whereas  the 


Fig.  44. — Aneurism  of  Femoral  Artery. 

a.  Thickened  walls  of  ttie  artery  forming  the  sac  of  the  aneurism  ;  the  coats 
are  indistinguishable  ;  &,  semi-detached  clot. 


more  recent  ones  do.  This  is  explained  by  the 
increase  in  size  of  the  aneurism.  The  lamination  is 
due  to  variations  in  the  rate  of  coagulation,  or  to  a 
succession  of  coagulations,  so  that  the  superficial  layer 
of  the  last  deposit  has  undergone  change  by  the  time 
coagulation  sets  in  again.  Moreover,  there  is  some- 
times an  alternation  of  j)ale  and  coloured  clots 
(Fig.  ■  45),  the  former  consisting  chiefly  of  fibrin,  the 
latter  of  coagulated  blood.  The  darker  strata  become 
paler  as  time  goes  on,  from  disintegration  of  the  red 
corpuscles  and  diffusion  and  absorption  of  the  hsemo- 
giobin. 


294 


Surgical  Pathology. 


[Chap.  LV. 


The  laminse  can  be  easily  separated  from  one 
another,  and  the  outermost  from  the  sac  of  the 
aneurism.  Irregular  softening  cavities  occasionally 
form  in  the  clots  of  large  aneurisms,  and  in  this  way 
fragments    may   be    detached    and    plug   the    vessel 


Fig.  45. — ^Aneurism  of  Middle  Cerebral  Artery.  (Natural  size.) 
a,  Sac  of  aneurism  laid  open,  and  showing  the  laminated  clot, &  and  d,  within  ;  c, 
black  coagulnm  ;  e,  ai'tery  ;  /,  space  left  hy  clot  shrinking  from  hardening 
in  alcohol.  The  older  periphei'al  part  of  the  clot  was  of  a  dark  reddish-hrown 
colour,  interspersed  with  two  pale  streaks.  Tne  more  recent  part  of  the  clot 
was  of  a  pale  fawn  colour,  with  the  exception  of  that  last  formed,  which 
was  black. 


beyond,  and  possibly  cause  gangrene.  If  the  laminse 
are  loosened  at  their  free  borders  blood  j^asses  into 
the  clefts,  and,  meeting  with  little  resistance  between 
the  layers,  separates  them  more  or  less.  Then  the 
interlaminar  spaces  fill  with  dark  coagula.  This  is 
another  explanation  of  the  alternation  of  pale  and 
coloured  clots  ;  but  in  such  cases  the  disposition  is 
very  irregular. 

From  natural  causes,  or  as  the  result  of  treatment, 
the  blood  in  the  sac  may  coagulate  en  masse. 
However  extensive  the  lamination,  the  final  oblitera- 
tion is  always  effected  by  simple  coagulation,  which 
extends  into  the  artery  on  each  side  of  the  aneurism. 
The  irritation  of  the  clot  causes  the  artery  to  inflame, 
and    this    ends    in    its    permanent    obliteration   by 


Chap.  Lv.]  Aneurism.  295 

organised  connective  tissue.  Tlie  danger  from  subse- 
quent softening  of  the  coagulum  in  the  aneurismal  sac 
is  not  great,  for  by  the  time  it  occurs  the  artery  is 
pretty  firmly  plugged. 

IJnder  the  microscope,  scrapings  from  the  laminated 
clot  show  fibrin  filaments,  fatty  debris,  granular  and 
crystalline  hs&matoidin,  and  plates  of  chloresterine. 

Changes  outside  the  aneiirism. — The  irri- 
tation from  expansion  of  the  sac  sets  up  inflammation 
around  it.  This  causes  a  thickening  of  the  sac  at  the 
expense  of  the  tissues,  which  undergo  gradual  absorp- 
tion, partly  from  inflammatory  softening,  partly  from 
diminution  in  the  blood  supply,  through  continuous 
pressure.  Where  the  irritation  is  slight,  the  exudation 
organises,  so  that  in  the  same  specimen  new  tissue 
formation  and  atrophy  may  be  seen  side  by  side 
(Fig.  3).  No  structure  is  able  to  withstand  the 
expanding  force  of  an  aneurism  \  thus,  the  sternum, 
ribs,  and  vertebrae  become  excavated  in  aneurism  of 
the  aorta.  Cornil  and  Ranvier  assert  that  rarefying 
ostitis  caused  by  the  pressure  of  the  sac  is  the  sole 
cause  of  the  absorption  of  bone.  No  doubt  it  is  an 
important  factor,  but  simple  atrophy  from  sustained 
pressure  must  not  be  forgotten.  In  some  cases  the 
inflammation  in  and  around  the  sac  goes  on  to 
suppuration.  This  inevitably  causes  rupture,  unless 
in  the  meantime  coagulation  has  taken  place  in  the 
aneurism  and  artery  beyond,  but  even  then  the  clot 
will  probably  disintegrate,  so  that  the  final  result  is  the 
same. 

The  superficial  veins  of  the  part  are  generally 
dilated,  from  obstruction  to  the  current  through  the 
main  trunk.     There  may  also  be  oedema. 

The  resistance  ofiered  to  the  blood  stream  as  it 
passes  through  the  aneurism  increases  the  tension  in 
the  side  branches  of  the  artery,  and  so  opens  up  the 
collateral   circulation.      For  this   reason  gangrene  of 


296  •  Surgical  Pathology.  [Chap.  lv. 

the  leg  is  less  likely  to  follow  ligature  of  the  femoral, 
for  a  large  or  medium-sized  than  for  a  small  aneurism. 
Hence  also  the  value  of  compression  preliminary  to 
ligature. 

The  existence  of  a  spontaneous  aneurism  is  evidence 
of  arterial  disease,  which  renders  the  vessels  rigid  and 
slow  to  expand. 

The  pulsation  of  the  artery  on  the  distal  side  of 
the  aneurism  is  usually  weak ;  at  the  same  time,  the 
artery  may  be  fuller  than  normal,  from  blood  entering 
it  in  many  collateral  streams. 

The  bruit  produced  in  the  sac  may  be  conducted 
for  a  considerable  distance  along  the  artery ;  e.g..,  in 
the  case  of  a  femoral  aneurism  it  may  sometimes  be 
heard  in  the  tibials.  This  is  an  important  diagnostic 
sign  between  aneurism  and  a  pulsating  malignant 
tumour,  where  the  bruit  arises  in  many  vessels  and 
away  from  the  main  trunk. 

Varieties  of  patlioSog^ieal  aneurism. — These 
are  named  :  (1)  From  the  composition  of  the  sac — • 
true  and  false ;  (2)  from  their  shape — sacculated, 
fusiform,  cylindrical,  and  racemose  or  cirsoid ;  (3) 
from  their  primary  origin — syphilitic,  embolic ;  (4) 
from  some  peculiarity  in  size,  course,  or  distribution 
— miliary,  dissecting,  etc. 

Fusiforan  aneurisms  only  attain  a  large  size 
in  the  case  of  the  aorta.  They  are  not  uncommon  in 
the  popliteal  arteries.  There  is  uniform  dilatation  of 
the  entire  circumference  of  the  vessel.  They  generally 
yield  at  one  part,  and  become  sacculated. 

Cirsoid  aneiirism.  —  Racemose  aneurism. — 
Aneurism  by  anastomosis  consists  of  a  dilatation  of  a 
connected  series  of  arteries,  or  of  a  single  artery  and 
its  branches.  They  are  most  common  in  the  scalp  and 
orbit,  but- they  are  met  with  in  other  parts,  e.g.,  the 
buttock.  The  vessels  are  enlarged  in  every  way,  they 
are  lengthened,  tortuous,  and   varicosed ;  their  walls 


Chap.  Lv.]  Aneurism.  297 

are  thickened,  and  their  lumen  increased.  Billroth 
believes  these  aneurisms  to  be  of  inflammatory  origin, 
since  they  sometimes  follow  injury,  and  their  walls 
contain  many  new-formed  cellular  elements.  In 
one  case  I  found  two  circumscribed  aneurisms  of  the 
internal  carotid,  one  just  outside  the  skull,  and  the 
other  in  the  cavernous  sinus;  and  also  uniform  dila- 
tation of  the  ophthalmic  artery  and  its  branches. 
There  was  protrusion  of  the  eye-ball.  The  patient  had 
shortly  before  been  kicked  by  a  horse  on  the  side  of 
the  head.  Ligature  of  the  common  carotid  failed  to 
cure  or  arrest  the  disease,  and  death  ensued  from 
cerebral  congestion.  In  another  patient  all  the 
arteries  of  the  scalp  were  dilated,  and  the  occipital 
was  as  large  as  the  little  finger.  By  their  pressure 
they  had  hollowed  out  the  cranial  bones  into  furrows. 

Emtooiic  aneurisms  are  mostly  intracranial. 
Vegetation  from  the  cardiac  valves  arrested  in  the 
cerebral  vessels  set  up  a  localised  arteritis.  Dilatation 
takes  place  at  these  spots.  Such  aneurisms  are 
relatively  common  in  children. 

Miliary  aneurisms  are  found  in  the  cerebral 
vessels.  They  are  quite  small,  often  no  larger  than  a 
pin's  head.  Some  are  microscopical.  They  are  usually 
multiple,  and  are  met  with  in  the  pia  mater  and  in 
the  substance  of  the  brain.  Atheroma  or  syphilis  is 
the  cause.  By  their  rupture  they  cause  apoplexy,  but 
previous  hsemorrhage  or  thrombosis  may  in  some  cases 
be  the  exciting  cause  of  the  dilatation,  the  obstruction 
in  front  throwing  strain  on  the  diseased  arteries. 

Hissecting:  aneurism.  —  An  "  atheromatous 
abscess  "  bursts  ;  blood  is  forced  between  the  middle 
and  external  coats,  or  more  probably  between  the 
layers  of  the  middle  coat  (Peacock).  The  channel 
thus  formed  opens  again  into  the  lumen  of  the 
artery,  when  it  meets  with  a  softening  focus  or 
another  ulcer ;  or  it  ends  in  a  sacculated  aneurism  of 


298 


Surgical  Pathology. 


[Chap.  LVI. 


the  internal  or  external  coat,  and  then  it  obstructs  the 
artery,  or  ruptures  externally.  Dissecting  aneurism 
is  not  met  with  in  the  small  arteries.  It  is  most 
common  in  the  aorta. 


CHAPTEE  LVI. 


LIGATURE    OF   AETERIES. 


When  an  artery  is  tied  the  internal  and  external 
coats  are  cleanly  divided,  but  they  do  not  curl  up  as 
in  torsion.  The  external 
coat  is  thrown  into  folds, 
and  the  convolutions  are 
welded  together  by  the 
ligature.  The  injury  in- 
flicted on  the  vessel  induces 
coagulation,  which  extends 
on  each  side  to  the  next 
collateral  branch.  The 
clot  is  pyramidal,  ^vith  its 
base  at  the  seat  of  ligature. 
At  first  it  fills  the  artery 
for  some  little  distance, 
but  it  shrinks  as  the  con- 


tracting   fibrin 


the 


expresses 
This  allows 


serum. 

Fig.  46.— Common  ,1111,  ,      , 

Carotid    Artery  tlie  Diood  to  pass  between 

of    a    Child,    on..  -,.■■  ^      ,  ,,  , 

which  a  Catgut  it  ancl  tlie  vessci  wall,  and 

Ligature  was  ap-  />       ,  i  -,  •  ■    ,     i  i 

plied  three  days  lUrtlier  QOpOSlt  takCS  place, 

The    clot    has  Until  the   clot  is  more  or 

been  removed.  ,  •      n  i         •        ,     i 

a  points  to  the  fur-  ^^^s      spu^ally     laminated. 

Hga^u^t  \^hlc^  When    fully  formed  it  is 

tiTlnte^afand  fii^mly  adhcreiit  to  the  wall 

mMcUe  coats  of  the  ^f    ^j^^  ^^^^^j^  Within    a 


Fig.  47.— Portion  of 
Femoral  Artery 
examined  on  the 
fourth  day  after 
the  application  of 
a  Ligature. 

a.  Cardiac  extremit:? ; 
6,  division  of  the 
internal  and  middle 
coats  by  the  ligii- 
ture ;  c,  proximal 
thrombus ;  d,  distal 
thrombus ;  e,  origiu 
of  prof  nil  da  f  emori^ 
{After  Maneg.) 


Chap.  LVi.]         Ligature  of  Arteries.  299 

fortnight  it  is  quite  pale  from  solution  and  diffusion 
of  the  colouring  matter.  The  proximal  is  said  usually 
to  be  larger  than  the  distal  clot,  since  the  latter  is 
formed  under  greater  pressure,  and  is  more  disturbed 
by  the  inrush  of  blood  from  the  collateral  branches. 

The  so-called  secondary  clot  consists  of  inflammatory 
lymph,  and  cells  exuded  from  the  wall  of  the  vessel 
under  the  irritation  of  the  ligature.  The  exudation 
joins  the  primary  clot  about  its  base  and  sides,  and  is 
in  fact  incorporated  with  it.  Organisation  ensues, 
and  the  lumen  of  the  vessel  is  obliterated  by  dense 
cicatricial  tissue.  Most  observers  agree  that  the  clot 
is  partly  absorbed  and  partly  organised.  Cornil  and 
Kanvier  say  that  it  is  wholly  absorbed,  and  that  the 
young  vascular  connective  tissue  that  fills  the  vessel  is 
entirely  derived  from  an  ingrowth  of  granulations 
from  the  inflamed  walls.  The  process  is  exactly  the 
same  as  in  occlusion  by  spontaneous  thrombi  (Tig.  50). 

As  the  vasa-vasorum  run  for  a  short  distance 
within  the  sheath  before  penetrating  the  coats  of  the 
vessel,  it  is  clear  that  the  vascular  supply  to  the 
arterial  walls  will  be  somewhat  defective  immediately 
on  the  distal  side  of  the  ligature.  Moreover,  as  the 
collateral  circulation  is  being  established  the  tension 
is  constantly  being  raised  on  the  distal  side  and 
lowered  on  the  proximal.  The  better  nutritive  supply 
and  the  greater  quiescence  explain  why  the  artery  on 
the  proximal  side  of  the  ligature  is  more  firmly 
occluded  than  on  the  distal ;  and  why  in  the  case  of 
secondary  haemorrhage  the  blood  more  often  issues 
from  the  distal  portion. 

Cutting:  through  of  the  ligature. — What 
happens  is  as  follows  :  The  portion  of  external  coat 
gripped  by  the  ligature  is  killed  outright,  and  has  to 
be  cast  ofi"  like  any  other  slough.  This  is  efi'ected 
by  a  true  process  of  ulceration.  A  layer  of  granula- 
tion  tissue  forms   on  each  side,  the  ligature  holding 


^3oo  Surgical  Pathology.         [Chap.  lvii. 

the  necrosed  portion  of  the  artery.  It  is  true  the 
latter  is  not  seen  on  examining  the  loop  of  the  liga- 
ture, for  it  disintegrates  whilst  it  is  being  set  free. 
Catgut  ligature  melts  awaj  after  a  few  daj'S,  and 
whatever  portion  of  the  artery  has  lost  its  vitality  is 
removed  by  absorption.  If  the  artery  be  loosely  tied 
with  catgut  ligature,  occlusion  may  be  effected  without 
loss  of  tissue,  exactly  as  in  spontaneous  thrombosis. 


CHAPTEU  LYII. 

VARIX. 

Definition. — Yarix  is  an  uneven  or  pouch-like 
dilatation  of  the  veins, the  walls  of  which  are  thickened, 
and  the  lumen  widened  and  lengthened. 

Causes. — The  exciting  and  sufficient  cause  is  the 
strain  from  obstruction  to  venous  circulation ;  but 
besides  this  there  is  often  a  predisposition  to  the 
disease  from  inherent  weakness  of  the  coats  of  the 
veins.  The  obstruction  may  be  temporary,  e.g.^  the 
pressure  of  a  tumour ;  recurrent,  as  in  repeated  preg- 
nancies ;  or  permanent,  as  in  aneurismal  varix. 

Consequences. — (1)  Thrombosis  and  phlebitis, 
as  in  inflamed  piles ;  (2)  ulceration  (in  the  leg) ;  (3) 
atrophy  of  structures,  e.g.,  the  testicle,  from  vari- 
cocele, this  arising  partly  from  pressure  and  partly 
from  deprivation  of  projDerly  oxygenated  blood. 

Usnal  seats  of  varix. — The  •  lower  extremity  ; 
the  prostatic,  spermatic,  and  hsemorrhoidal  plexuses  ; 
and  the  neighbourhood  of  arteries  (aneurismal  varix 
and  varicose  aneurism). 

The  veins  of  the  lower  extremity  suffer  more  than 
those  of  the  upper:  (1)  Because  the  force  of  gravity 
acts   more  continuously  against  the  direction  of  the 


Chap.  LVII.]  VaRTX.  30I 

venous  blood-stream  ;  (2)  because  contraction  of  the 
muscles  of  the  lower  limb  is  greater  and  more  con- 
tinuous, and  the  blood  from  the  deep  intermuscular 
veins  is  forced  into  the  superficial  ones  to  a  corre- 
sponding extent  (advantage  is  taken  of  this  compen- 
satory dilatation,  in  the  operation  of  venesection); 
(3)  accidental  pressure  upon  the  inferior  vena  cava 
and  iliac  veins  is  more  common  than  upon  the  superior 
vena  cava  and  innominates. 

Oeneral  pattiology.  —  By  some  the  initial 
change  is  described  as  inflammatory,  whereas  others 
look  upon  it  as  a  mere  fibroid  substitution,  that  is  to 
say,  the  normal  elements  of  the  coats  are  to  a  great 
extent  replaced  by  a  low  form  of  connective  tissue,  the 
same  as  is  seen  in  nutmeg  cirrhosis  of  the  liver.  In 
both  cases  the  increase  of  fibrous  tissue  follows 
chronic  obstruction  to  the  flow  of  blood  through  the 
veins.  Formerly  these  changes  were  considered  as 
inflammatory,  now  it  is  the  fashion  to  speak  of  them 
as  "  cirrhoses,"  "scleroses,"  or  "fibroses."  It  is  diffi- 
cult to  diflerentiate  the  two,  for  whilst  the  usual  signs 
of  inflammation  are  not  marked,  because  they  are 
very  slight  and  spread  over  a  long  period,  the  final 
result  is  the  same  as  one  of  the  typical  terminations 
of  undoubted  chronic  inflammations,  that  isj  the  pro- 
duction of  cicatricial  tissue. 

Those  who  reject  the  inflammatoty  theory  assert 
that  the  stagnation  in  the  veins  prevents  their  coats 
from  being  properly  replenished  (for  if  the  current 
through  the  veins  is  obstructed  it  is  clear  that 
the  tributary  vasa-vasorum  cannot  discharge  their" 
contents  with  natural  freedom).  They  say  that  the 
deoxydised  blood  suffices  for  the  nourishment  of  con- 
nective tissue,  but  is  not  equal  to  the  support  of  more 
highly  organised  structures  such  as  muscular  fibre. 

We  refuse  to  accept  this  as  the  entire  explanation^ 
(1)  because  the  efiect  of  strain,  which  is  traumatism. 


302  Surgical  Pathology.  [Chap.  lvii. 

long  drawn  out,  perhaps,  but  none  the  less  traumatism, 
is  ignored ;  (2)  because  the  areolar  tissue  around 
the  veins  is  much  condensed  and  thickened  by 
material  that  is  more  vascular  and  corpuscular  than 
normal. 

There  is  degeneration  from  chronic  starvation,  and 
inflammatory  thickening  from  strain. 

As  before  said,  there  is  general  increase  in  the 
width  and  length  of  the  veins.  They  dilate  in  spite 
of  the  thickness  of  the  walls,  for  the  intravascular 
pressure  is  raised  ah  initio,  and  the  altered  structure 
is  less  able  to  bear  the  strain  thrown  upon  it.  On 
account  of  the  great  elongation  the  veins  become 
curved  in  a  remarkable  manner.  Then  follows 
varicosity,  (1)  because  the  obstruction  tells  most  at 
the  seat  of  the  valves ;  (2)  because  the  blood 
stream  is  diverted  from  its  rectilinear  course, 
and  its  impact  is  greater  on  the  convex  side  of 
each  curve  as  seen  from  without,  like  as  a  river 
hollows  its  banks  here  and  there  in  its  winding 
channel. 

Histology. — On  opening  a  varicosed  vein  the 
inner  surface  looks  rough  from  a  longitudinal  striation. 
Under  the  microscope  this  is  seen  to  be  due  to  coarse 
bundles  of  connective  tissue  interlacing  with  the 
elastic  fibres  of  the  inner  portion  of  the  middle  coat, 
and  greatly  obscuring  them.  The  muscular  fibres  at 
first  undergo  a  compensatory  hypertrophy,  and  on 
section  lengthwise  of  the  vein  appear,  if  stained  with 
logwood,  as  pale  circles  with  dark  central  spots — 
muscular  fibre-cells  and  their  nuclei  respectively. 
Eventually  the  muscular  and  elastic  elements  are  so 
overrun  by  fibroid  overgrowth  that  nothing  can  be 
seen  but  a  partly  fibrillated,  partly  homogeneous,  scar- 
like tissue,  in  which  are  embedded  granules  oi  ingment, 
scattered,  or  in  groups.  The  vasa-vasorum  are  dilated 
and  their  coats  thickened. 


Chap.  LVIL]  VaRIX.  303 

Calcification  may  take  place,  (1)  in  tlie  form  of 

plates  in  the  walls  of  tlie  veins ;  (2)  as  phleholitJis 
in.  the  interior,  and  probably  in  the  remains  of  blood- 
clots  that  have  formed  about  the  valves.  They  are 
most  common  in  the  prostatic  veins. 

The  valves,  which  are  merely  reduplications  of 
the  lining  membrane,  suffer  in  the  same  way  as  the 
walls  of  the  veins  ;  that  is,  they  become  thicker  and 
less  pliant.  Their  function  is  soon  lost,  for  they 
undergo  cicatricial  contraction,  whilst  the  lumen  of 
the  vein  is  increased.  In  the  end  they  shrink  to  mere 
caruncles,  or  even  disappear.  Should  one  of  the 
ampuUary  dilatations  of  a  greatly  distended  super- 
ficial vein  rupture,  blood  will  issue  from  the  proximal 
and  distal  sides  of  the  opening.  The  more  dangerous 
bleeding  often  comes  from  the  proximal  side,  for  the 
valves  no  longer  suffice  to  support  the  column  of  blood 
above  them  (it  may  be  from  the  vena  cava  down- 
wards) ;  and  the  weight  of  this  column  causes  a  con- 
tinuous downpour,  which  may  end  fatally  in  a  few 
minutes,  unless  checked  by  pressure  or  by  elevation 
of  the  limb. 

Clianges  around  the  veins. — The  areolar 
tissue  in  which  the  veins  lie  is  congested  and  infil- 
trated with  inflammatory  exudation.  The  exudation 
becomes  indurated  and  firmly  united  to  the  veins,  so 
that  the  latter  are  more  or  less  fixed.  This  accounts 
for  the  feeling  of  a  shallow  trench  in  the  skin  and 
subcutaneous  tissue  when  the  finger  is  pressed  fiiTuly 
along  the  course  of  a  dilated  vein.  *'  The  fixation  of 
the  veins,  together  with  the  thickening  and  rigidity 
of  their  walls,  prevents  them  from  collapsing  when 
wounded,  and  so  favours  heemorrhao-e. 

Pigmentation  of  the  skin  and  cellular  tissue  results 
from  capillary  extravasation,  and  transudation  of  red 
corpuscles.  The  discoloration  around  varicosed  veins 
of  the  leg  is  often  very  marked. 


304  Surgical  Pathology.        [Chap.  lviii. 

The  localised  thinnings  that  lead  to  rupture  are 
due  to  extreme  distention  of  varicosities  behind  the 
valves,  and  to  want  of  support  from  without.  Thus 
we  often  find  that  the  superficial  part  of  the  vein, 
together  with  the  atrophied  skin  over  it,  is  not  so 
thick  as  the  deeper  portion  of  the  vein  alone. 


CHAPTER   LYIIL 

EMBOLISM. 

Embolism,  or  the  conveyance  and  subsequent 
arrest  of  foreign  bodies  in  the  blood  current,  begins 
either  on  the  arterial  or  venous  side  of  the  circulation. 

The    soiu'ces    of   arterial    esiibolisiii    are  : 

vegetations  from  the  cardiac  valves,  clots  dislodged 
from  the  sac  of  an  aneurism,  the  contents  of  an  "  athero- 
matous abscess,"  and  calcified  plates  and  thrombi  from 
the  walls  of  the  large  arteries. 

Venous  embolism  usually  results  from  the 
detachment  of  clots.  In  fracture  of  bones,  and 
laceration  of  adipose  tissue,  liquid  fat  sometimes  makes 
its  way  into  the  open  veins.  The  entrance  of  air  in 
the  case  of  wounds  of  veins  within  the  "  dangerous 
region  "  is  well  known,  and  the  symptoms  in  these 
cases  are  probably  the  consequence  of  plugging  of  the 
pulmonary  vessels  by  aerial  emboli. 

Less  common  causes  of  embolism  are,  aggrega- 
tions of  pigment  granules,  portions  of  new  growths 
swept  off"  from  the  interior  of  vessels  which  they 
have  invaded,  pus  from  the  bursting  of  an  abscess, 
and  parasites. 

The  effects  of  embolism.  —  The  immediate 
effect  of  embolism  is  anaemia  of  the  part  supplied 
by  the  obstructed  vessel;  but  inasmuch  as  there  is  in 


Chap.  LVIIL] 


Embolism. 


305 


most  cases  a  free  collateral  circulation,  blood  makes 
its  way  in  by  the  side  channels,  and  if  the  embolus  be 
rigid  only  partial  occlusion  may  occur ;  this  also 
happens  when  it  is  arrested  at  the  point  of  bifurcation 
of  an  artery,  for  then  it  may  not  be  large  enough 
to    completely    close 


either  branch. 
Where  the  collateral 
circulation  is  but 
little  developed,  as 
in  the  intermediate- 
sized  vessels  of  the 
brain,  a  venous  reflux 
ensues,  which  soon 
leads  to  stasis,  since 
the  pressure  in  front 
is  no  longer  over- 
come by  the  force 
of  the  current  in  the 
artery. 

The  embolus,  act- 
ing as  a  foreign  body, 


Fig.  4S, 


-Diagram  of  Embolic  Congestion 
of  the  Lung. 

a.  Small  artery  rlngsed  at  e  by  an  eraholiis  ;  v, 
small  vein  filled  with  a  clot,  wliirli  extends  as 
far  as  its  trunk  ;  the  shaded  portion  of  the 
capillary  network  is  the  area  of  distribution 
of  the  artery,  in  a  state  of  passive  congestion, 
and  about  to  be  the  seat  of  a  hemorrhagic 
exudation.  The  arrows  show  the  collateral 
channels  through  which  the  abnormal  tur- 
gescence  is  effected  (Rindfleisch). 


causes  coagulation  of 
the  blood  upon  it. 
This  reaches  to  the 
first  collateral  branch, 
where  its  progi^ess 
is  arrested,  provided 

the  anastomosis  is  sufficiently  free.  When  it  is 
defective,  and  especially  if  a  number  of  contiguous 
branches  of  the  same  vessel  be  occluded,  the  blood 
stagnates,  and  the  whole  area  becomes  the  seat  of 
secondary  thrombosis.  This,  however,  takes  some  time 
to  become  complete;  and  in  the  meanwhile,  the  walls 
of  the  capillaries,  suffering  from  impaired  nutrition, 
readily  allow  the  passage  of  blood  corpuscles,  and  pro- 
bably many  capillaries  actually  rupture,  the  more  so 
u 


3o6  Surgical  Pathology.         [Chap.  lviii. 

as  the  strain  upon  them  is  increased  by  the  disten- 
tion of  the  congested  vessels  around.  This  is  what 
is  termed  hcemorrhagic  infarction. 

The  size  of  the  embolus  will  depend  upon  its 
source  and  its  consistence.  If  it  be  derived  from  a 
calcified  cardiac  vegetation,  or  an  atheromatous  plate 
from  an  artery,  it  will  withstand  the  impact  against 
the  walls  of  the  vessels.  Should  it  consist  of  a 
softened  venous  thrombus  it  will  very  likely  be  broken 
up  in  its  onward  course,  the  several  portions  being 
scattered  in  an  embolic  shower.  A  vessel  may  not  be 
completely  blocked  by  an  embolus,  but  later  on  occlu- 
sion may  ensue  from  coagulation  of  the  blood  upon 
the  embolus. 

The  effect  upon  tlie  Tvall  of  tlie  vessel  will 
vary  as  to  the  nature  and  duration  of  the  plugging. 
If  the  embolus  consist  of  a  healthy  thrombus  it  may 
be  quickly  absorbed,  leaving  the  structure  of  the 
vessel  intact ;  or  it  may  become  adherent  and  organise, 
the  lumen  in  this  way  being  permanently  obliterated. 
A  rough  body,  such  as  a  calcified  vegetation,  will 
irritate  mechanically,  and  cause  thickening  of  the 
coats  of  the  vessel.  A  portion  of  a  tumour  may 
infect  the  part  at  which  it  is  arrested,  and  form  the 
centre  of  a  fresh  growth.  Lastly,  from  whatever 
source,  a  septic  embolus  invariably  leads  to  acute 
inflammation  and  necrosis. 

Paths  of  transit. — Since  as  a  rule  the  emboli 
are  comparatively  small,  and  tend  to  take  a  direct 
course,  it  is  clear  that  the  periphery  of  an  organ  will 
be  more  often  the  seat  of  the  lesion  than  the  centre, 
hence  in  the  lungs  the  posterior  bases  suffer  most. 
Inasmuch  as  they  are  carried  along  the  main  course  of 
the  blood  stream,  they  will  pass  into  the  thoracic 
aorta  rather  than  travel  through  the  innominate, 
carotid,  and  subclavian  orifices.  So,  again,  they  will 
be  found  in  the  left  carotid,  renal,  and  iliac  arteries 


Chap.  LVIIL]     H.EMORRHAGIC    INFARCTION.  307 

more  often  than  in  the  right.  In  a  few  instances,  e.g.^ 
in  the  middle  cerebral,  coronary  of  the  heart,  and 
branches  of  the  coeliac  axis,  their  course  is  almost 
at  a  right  angle  to  that  of  the  parent  vessel. 

When  the  embolus  starts  on  the  venous  side  of 
the  circulation  (which  it  usually  does,  and  in  the 
form  of  detached  clots)  its  arrest  usually  takes  place 
in  the  lungs,  and  the  pulmonary  capillaries  filtering 
the  blood  prevent  the  distribution  of  the  solid  particles 
in  other  organs  or  tissues.  But  these  capillaries  are 
comparatively  large,  and  are  still  further  dilated  in 
any  disease  that  raises  the  pulmonary  pressure  ;  hence, 
it  is  not  very  uncommon  to  find  that  some  of  the 
smallest  emboli  make  their  way  through  the  lungs  and 
left  side  of  the  heart  into  the  aortic  system.  Still  there 
is  no  doubt  that  many  of  the  metastatic  abscesses  found 
in  other  organs  than  the  lungs  in  pyaemia  are  the  sequel 
of  primary  thrombosis,  and  not  of  embolic  infarction. 

In  cases  where  the  abscesses  are  found  only  in  the 
liver  (excluding  those  of  portal  origin),  the  same 
explanation  seems  more  probable  than  that  which 
^supposes  the  emboli  to  have  passed  from  one  or  other 
cava  into  the  hepatic  veins,  or,  in  other  words, 
against  the  blood  current  \  although  in  severe  obstruc- 
tive disease  of  the  chest  the  systemic  venous 
pressure  may  be  so  increased  as  to  become  positive. 

Thrombi,  or  portions  of  new  growth  set  free 
from  branches  of  the  portal  vein,  will  be  conveyed  to 
the  liver,  and  there  probably  entirely  arrested. 

Hsemorrliagit^  infarction  has  been  already 
adverted  to.  It  consists  of  secondary  thrombosis, 
startino-  from  an  embolus  and  extending  throusfh  a 
part  or  the  whole  of  the  area  supplied  by  the  obstructed 
artery,  and,  as  a  result,  exudation  from  the  vessels, 
extravasation  of  blood  from  rupture  of  capillaries,  and 
the  formation  of  an  intense  hyper£emic  inflammatory 
zone   around.      These  infarctions   are   mostly   wedge- 


3o8 


Surgical  Pathology 


[Chap.  LVIII. 


shaped,  for  the  vessels  divide  again   and  again,   the 
area  of  distribution  gradually  widening  (Fig.  49). 

The  pathological  changes  that  ensue  depend  :  (1) 
Upon  the  size  of  the  infarction;  (2)  upon  the  degree 
of  freedom  of  anastomosis  ;    (3)  upon  the  nature  of 

the  plug,  whether  it 
be  simjole  or  septic. 
"  If  the  embolus  be 
small  and  the  colla- 
teral circulation  free, 
a  quick  absorption  of 
the  clot  in  the  throm- 
bosed vessels  is  the 
usual  result,  and  the 
part  is  thus  restored 
to  its  healthy  condi- 
tion. If  the  embolus 
be  large,  but  not 
septic,  the  area  of 
infarction  is  too  wide 
for  the  thrombosed 
vessels  to  be  cleared 
before  fatty  degenera- 
tion takes  place  in  the  tissues  (including  the  walls  of 
the  vessels  themselves)  cut  off  from  their  blood  supply. 
In  this  case  the  colouring  matter  of  the  coagulated 
and  extravasated  blood  is  discharged  from  the  cor- 
puscles, and,  with  the  more  fluid  portion,  is  absorbed 
by  the  surrounding  vessels,  leaving  a  firm  yellowish- 
white  putty-like  mass,  composed  of  degenerated  tissue 
and  blood  clot,  closely  resembling  a  syj)hilitic  gumma, 
for  which,  indeed,  it  is  sometimes  mistaken  ;  but  a 
gumma  is  harder,  and  is  not  conical  in  shape,  nor  is  it 
surrounded  by  such  an  intensely  congested  zone.  This 
mass,  in  its  turn,  is  gradually  reduced  in  size  by 
absorption  of  the  debris  resulting  from  the  disintegra- 
tion,   until   at   last    a   contracted    puckered    cicatrix, 


Fig.  49. — Embolic  Infarction  of  Spleen. 

The  wedge-shaped  masses  are  partially  de- 
colorised. This  is  farther  advanced  at  the 
periphery,  6,  than  in  the  central  portion,  c. 
Each  block  is  surrounded  by  a  zone  of  hype- 
ragmia,  a ;  d,  outer  surface  of  the  organ. 


Chap.  LViii.]  Embolism.  309 

infiltrated,  perhaps,  with  lime-salts,  and  containing 
some  pigment  granules,  and,  in  the  case  of  the  brain, 
hsematoidin  crystals,  is  all  that  remains. 

If  the  infarction  start  from  a  septic  embolus, 
whether  it  be  large  or  small,  the  intense  irritation  will 
invariably  lead  to  the  formation  of  a  circumscribed 
metastatic  abscess,  the  contents  of  such  abscess  con- 
sisting of  inflammatory  exudation,  disintegrated  clot, 
and  broken-down  tissue. 

Oeneral  effects  of  emboHsm. — The  original 
embolus  may  be  so  small,  or  it  may  crumble  into 
such  minute  fragments,  that  only  the  capillaries  are 
blocked,  and  unless  in  this  case  it  be  septic,  or  some 
vital  organ,  such  as  the  brain  or  heart,  be  involved,  it 
will  probably  lead  to  no  further  trouble.  On  the  other 
hand,  it  may  be  of  such  a  size  as  to  cause  almost 
instant  death,  as  when  large  vegetations  from  a  cardiac 
valve  find  their  way  into  the  cerebral  vessels,  or  a 
thrombus  loosened  from  an  iliac  vein  plugs  the  trunk 
or  main  branches  of  the  pulmonary  artery. 

Besides  the  immediate  danger  in  such  cases,  and 
the  almost  certainty  of  death  in  septic  embolism  of 
the  internal  organs,  there  are  others  of  great  gravity. 

Gangrene  of  the  leg  may  follow  the  accidental 
plugging  of  the  popliteal  artery  by  a  clot  from  an 
aneurism  seated  on  the  same  A^essel,  the  opening  up 
of  the  collateral  circulation  being  too  long  impeded  by 
the  rigidity  of  the  diseased  vessels, 

AneitrisTii  of  the  cerebral  arteries  often  owes  its 
origin  to  the  degeneration  consequent  on  the  pressure 
of  an  embolus  ;  the  walls  softening  from  inflammation 
give  way  at  first  on  the  proximal  side  of  the  obstruc- 
tion. The  source  of  the  embolism  is  frequently  de- 
tachment of  vegetations  from  the  cardiac  valves  after 
rheumatic  fever,  and  this  explains  the  apparent 
anomaly  of  pathological  aneurisms  occurring  in 
children. 


CHAPTER  LIX. 

THROMBOSIS    AND    PHLEBITIS. 

Thrombosis  is  a  clotting  of  the  blood  in  the 
vessels.  Concerning  the  coagulation  of  blood  drawn 
from  the  vessels,  it  can  be  shown  that  it  is  due  to  the 
interaction  of  three  bodies,  fibrinoplastin,  fibrinogen, 
and  a  ferment  resulting  in  a  combination  of  the  two 
former  ;  that  is  to  say,  fibrin  which  does  not  exist  in 
the  blood  comes  to  be  formed  under  certain  ascertain- 
able conditions  as  the  latter  becomes  solid.  There  is, 
so  to  speak,  a  constant  antagonism  between  two  sets 
of  influences,  between  those  that  favour  and  those 
that  retard  or  prevent  coagulation.  Amongst  the 
former  are  :  1.  Rapid  motion,  as  in  whipping,  or,  in 
other  w^ords,  multiplication  of  points  of  contact.  2. 
Exposure  to  not  living  matter.  Amongst  the  latter  we 
have  :  (1)  The  addition  of  a  third  of  the  bulk  of  some 
neutral  salt ;  (2)  a  temperature  of  about  32°  Fahr.  ; 
(3)  moderate  heat ;  (4)  the  abstraction  of  haemoglo- 
bin ;  (5)  the  absence  of  a  neutra.l  salt,  whose  presence, 
accordinof  to  Schmidt,  is  essential  to  coao-ulation. 

Now  blood,  whilst  in  the  vessels,  is  known  to  clot 
more  easily  when  the  current  is  slowed,  just  the 
reverse  of  what  is  found  in  shed  blood  ;  but  this  is 
only  an  apparent  anomaly,  for  slowing  of  the  blood 
current  means  a  diminution  in  the  nutrition  of  the 
coats  of  the  vessel,  and  this  brings  it  to  a  state  of 
lower  vitality,  and  so  the  question  of  slowness  or 
rapidity  of  motion  is  resolved  into  that  of  contact  with 
foreign  matter.  As  to  the  so-called  ferment,  the 
conditions  under  which  the  consequences  of  its  action 
are  brought  about  in  the  living  body  cannot  be 
doubted  ;  and  it  is  here  that  the  antiseptic  treatment- 


Chap.  Lix.]  Thrombosis.  311 

of  wounds  shows  itself  to  advantage,  for  when 
decomposition  of  the  discharges  is  allowed  to  take 
place  unchecked,  how  much  more  likely  is  thrombosis 
to  extend  beyond  the  immediate  seat  of  injury,  how 
much  more  likely  a  rapid  softening  of  the  clot,  and,  as 
a  natural  consequence,  detachment  of  emboli  rife  with 
mischief,  by  reason  of  their  mechanical  action,  and  still 
more  so  from  their  being  saturated  with  septic  matter. 

The  two  prominent  features  of  thrombosis  are :  (.1) 
Its  causation ;  (2)  the  fate  of  the  clot. 

Causes  of  tlirombosis. — To  gain  some  clue  to 
an  answer  to  the  question,  why  does  the  blood 
coagulate  in  the  vessels'?  the  diseased  states  not 
seldom  complicated  with  this  result  must  be  considered. 
Amongst  others,  the  following  cases  have  occurred  in 
the  experience  of  the  author  :  thrombosis  of  the 
cerebral  veins  in  phthisis  and  marasmus  ;  of  the  veins 
of  the  upper  limb,  in  septicaemia,  from  compound 
fracture  of  the  jaw;  of  the  pulmonary  artery,  fatal 
when  the  aseptic  wound  from  amputation  of  the 
breast  was  all  but  healed;  of  the  varicose  veins  of 
the  lower  extremity  ;  of  axillary  and  femoral  veins  in 
post-parturient  women ;  of  the  axillary  vein  in 
rheumatic  fever  ;  of  the  brachial  artery,  from  bruising. 
To  these  may  be  added,  the  plugging  of  the  cerebral 
arteries  in  syphilis ;  capillary  thrombosis,  as  the 
essential  pathology  of  cancrum  oris,  and  as  the 
explanation  of  the  multiple  openings  in  carbuncle 
(Billroth) ;  not  forgetting  those  cases  where  coagulation 
is  intentionally  induced,  as  in  the  ligation  of  arteries 
and  the  operations  for  varicosed  veins. 

The  conclusion  to  be  drawn  from  the  foregoing 
statements  is,  that  there  are  two  diseased  conditions, 
one  of  the  vessels,  the  other  of  the  blood,  that  act 
as  the  proximate  causes  of  thrombosis. 

Slowing:  of  the  blood  current  from  weakness  of 
the  heart  is  a  subsidiary  factor. 


312  Surgical  Pathology.  [Chap. lix. 

Causeis  foioid.  in  tlie  tolood. — The  blood  may 
be  so  vitiated  that  it  can  no  longer  maintain  its 
fluidity,  from  {a)  increase  in  the  fibrin  factors,  (6) 
excess  of  excrementitious  matter,  from  defective 
elimination,  as  in  gout,  or  the  introduction  of  infective 
material,  as  in  septicaemia. 

Causes  in  tiae  vessels. — Alteration  in  the 
structure  of  the  vessels  from  defective  nutrition  can 
be  explained  in  three  ways  :  1.  Those  conditions 
that  tend  to  slow  the  blood  current ;  such  as  («) 
varicosed  veins ;  (6)  atheromatous  and  calcareous 
arteries,  and  aneurismal  sacs  ;  (c)  obstruction  from 
without,  as  by  ligature,  or  the  pressure  of  a  tumour, 
or  inflammatory  exudation,  causing  great  capillary 
tension ;  {d)  venous  reflux  into  capillary  areas,  from 
embolism  of  the  arteries  feeding  them ;  (e)  feeble 
cardiac  action,  either  from  fatty  degeneration,  or  acute 
myocarditis,  or  a  deficient  output  of  energy  from  want 
of  the  proper  amount  of  stimulus,  as  when  a  person  of 
active  habits  is  suddenly  confined  to  bed  by  an 
accident.  2.  {a)  The  influence  of  inflammatory 
states,  such  as  occur  in  subacute  and  chronic  arteritis ; 
(6)  simple  degeneration  of  the  vessel  walls.  3.  The 
immediate  efiect  of  injury,  that  is,  before  there  is 
time  for  inflammatory  action  to  supervene. 

The  state  of  nutrition  of  the  tissues  to  be  nourished 
must  necessarily  affect  the  quality  of  the  blood,  and 
so  indirectly  lead  to  its  clotting. 

Relation  of  tliromtoosis  to  plilebitis. —  The 
microscopical  changes  that  are  found  in  thrombosis 
have  been  studied  chiefly  in  the  veins,  where  coagula- 
tion is  much  more  common  than  in  the  arteries,  and 
for  a  long  time  phlebitis  was  considered  the  cause  of 
thrombosis ;  the  order  of  things  is  now  reversed,  for, 
except  in  rare  instances,  there  can  be  no  doubt  but 
that  coagulation  precedes  inflammation.  Some  patho- 
logists   ignore    the    existence    of    an    endophlebitis, 


Chap.  Lix.]  Phlebitis.  313 

admitting  only  a  periphlebitis  in  the  aclventitia  and  in 
the  areolar  tissue  around  the  vein.  Formerlj,  the 
si^ns  of  inflammation  aloni^  the  course  of  a  vein 
during  life,  and  the  redness  of  the  intima,  and  ofttimes 
puriform  contents  found  post-mortem,  were  looked 
upon  as  proofs  that  the  disease  was  primarily  and 
essentially  a  phlebitis.  The  first  criterion  is  useless, 
since  a  periphlebitis  would  equally  well  explain  the 
symptoms  ;  the  second  in  many  cases  admits  of 
another  interpretation,  since  it  can  be  shown  that  the 
discoloration  of  the  inner  coat  is  often  due  to 
staining  by  the  hsemogiobin  of  the  clot,  and  not  to 
inflammatory  hyperEemia ;  and  the  third  is  practically 
valueless,  for  in  most  cases  the  material  looked  upon 
as  a  mixture  of  pus  and  blood  is  in  reality  but  partially 
decolorised,  softened,  disintegrated  clot,  consisting  of 
fatty  and  granular  debris,  but  few  leucocytes  re- 
maining. Again,  thrombosis  follows  so  quickly  upon 
injury  to  a  vein  that  it  is  impossible  in  these  cases 
for  inflammation  to  have  intervened. 

It  cannot  be  denied,  however,  that  phlebitis  does 
occasionally  precede  and  cause  the  thrombosis ;  e.g.^ 
in  cellulitis,  where  the  vessels  are  attacked  from 
without  :  moreover,  the  walls  of  veins  are  sometimes 
infiltrated  with  the  anatomical  evidences  of  pus,  that 
is  to  say,  cells  which  cannot  be  told  from  pus  corpus- 
cles, and  the  same  may  be  said  of  the  clots  which 
those  veins  contain. 

Signs  of  phlebitis. — When  a  subcutaneous  vein 
is  inflamed  the  signs  are  very  manifest  :  redness  of 
the  skin  over  it,  a  hard  cord  with  nodular  swellings, 
i.e.,  the  occluded  vein  still  further  thickened  by  the 
exudation  of  lymph  around,  the  nodules  marking  the 
position  of  varicosities  and  the  valves.  It  may  be 
noted  that  as  the  clot  shrinks  or  is  absorbed  more 
quickly  from  the  internodal  portions,  small,  hard 
lumps  for  a  time  remain,  which  in  certain  situations 


314  Surgical  Pathology.  [Chap.  lix. 

{e.g.,  Scarjja's  triangle)  may  be  mistaken  for  indurated 
glands.  Then  there  will  be  oedema  from  obstruction 
of  the  current,  and  as  the  clotting  and  inflammation 
spread,  the  point  of  greatest  intensity  of  pain  will 
shift  along  the  course  of  the  vessel  from  day  to  day. 
It  is  by  no  means  rare  in  patients  with  shattered 
health  for  abscesses  to  form  here  and  there  around  the 
veins  that  have  become  plugged.  Post  mortem  it  is  a 
matter  of  some  difficulty  to  dissect  out  these  veins 
from  tlieir  bed  of  lymph,  which  later  on  is  either 
organised,  leaving  the  vessels  blocked,  or  is  absorbed, 
the  normal  condition  being  restored.  When  the  deep 
veins  are  thrombosed  there  is  often  no  redness  of 
the  skin,  but  the  pain,  oedema,  and  distention  of  the 
superficial  veins  point  to  the  pathological  chauges 
going  on  (phlegmasia  alba  dolens). 

When  diffuse  coagulation  occurs  in  a  main  artery 
and  its  companion  vein,  it  usually  begins  in  the  artery ; 
and,  again,  diffuse  thrombosis  of  an  artery  is  more 
frequently  attended  by  that  of  the  vein  than  mce  versa, 
for  when  a  vein  is  plugged,  the  nutrition  of  the  walls 
of  the  contiguous  artery  is  not  necessarily  much  inter- 
fered with,  but  when  the  circulation  in  the  artery  is 
stopped,  the  vasa-vasorum  that  supply  the  walls  of 
the  vein  are  also  obstructed,  and  so  a  starvation  of 
that  part  of  the  vein  ensues,  and  this  causes  a  dimi- 
nution of  vitality,  and  consequent  coagulation.  At 
the  same  time  it  is  likely  that  the  inflammatory  state 
outside  the  artery  thrombosed  may  have  some  share  in 
effecting  the  clotting  in  the  neighbouring  vein;  be- 
sides, it  is  certain  that  something  more  than  a  simple 
failure  of  nutrition  is  at  work,  else  how  comes  it  that 
coagulation  occurs  in  only  a  small  proportion  of  the 
cases  of  degenerated  vessels. 

The  fate  of  tlie  clot.  —  Absorption,  disintegra- 
tion, organisation,  and  suppuration  are  the  secondary 
changes  occurring  in  the  thrombus.      Except  in  the 


ch  ap.  L I X.  ]  Thr  ombosis.  3  1 5 

case  of  septic  thrombosis,  where,  if  life  be  sufficiently 
prolonged  softening  always  ensues,  ahsorjotion  is  per- 
haps the  most  common  event.  This  is  often  seen  in 
varicose  veins  that  have  been  treated  by  simple  com- 
pression, where  after  temporary  occlusion  the  channel 
is  re-established.  Absorption  may  proceed  by  a  gradual 
disintegration  of  the  central  part  of  the  clot,  the  blood 
current  passing  through  the  latter,  which  in  the  end 
is  entirely  removed ;  or  wasting  may  slowly  progress 
from  the  periphery  until  only  a  fine  filamentous  cord 
of  fibrin  entangling  white  corpuscles  (for  the  red  ones 
break  up  early)  is  all  that  can  be  seen ;  and  this 
finally  disappears,  leaving  the  lumen  of  the  vessel 
completely  free.  Embolism  in  these  cases  is  prevented 
by  the  clot  in  the  main  vessel  being  kept  in  position 
by  offshoots  into  the  tributary  branches.  After 
alDSorption  is  complete,  staining  of  the  intima  persists 
for  some  time.  Disintegration  occurs  in  all  septic 
thrombi  and  in  large  simple  clots  where  the  blood 
supply  is  defective  :  thus  in  aneurisms  that  have  been 
consolidated  by  rapid  coagulation  of  the  blood  en 
7nasse,  as  in  those  of  the  popliteal  artery  treated  by 
Esmarch's  rubber  and  cord,  it  is  by  no  means  rare  to 
find  fluctuation  after  some  days.  It  would  be  a  grave 
error  in  practice  to  mistake  this  liquefaction  in  the 
centre  of  the  clot  for  suppuration.  Such  cases  require 
great  care  in  the  after-treatment,  for  it  is  difficult 
to  say  the  exact  extent  of  the  softening,  and  in- 
judicious manipulation  might  dislodge  a  portion  of  the 
contents  and  force  it  into  the  trunk  and  branches 
beyond.  Although  a  healthy  clot  projecting  into  a 
vein  may  be  broken  off  by  the  impact  of  the  blood 
stream,  by  careless  handling,  or  by  movement  on  the 
pari  of  the  patient  (particularly  flexion  of  the  hip  when 
the  ilio-femoral  vein  is  thrombosed) ;  still  such  an  event 
rarely  happens,  unless  there  be  loss  of  consistence  and 
tenacity  from  disintegration.     It  is   the  existence  of 


3i6 


Surgical  Pathology, 


[Chap.  LIX. 


this  softening  in  pyaemia  that  explains  the  very  fre- 
quent occurrence  of  embolic  abscesses  and  infarctions. 
Org'aiiiisatioii  of  tlie  clot. — In  some  text- 
books it  is  stated  that  after  phlebitis  the  vein  some- 
times shrmks    to   a    "  fibro  -  cellular   cord ; "    this   is 


Fig,  50. — Organised  Thrombus  in  Common  Carotid  Artery  from  a  Case 
of  Aneurism  of  tlie  Aorta. 

a,  Tunica  adventitia ;  6,  tunica  media ;  c,  tunica  intima  ;  <f,  vascularised  throm- 
bus united  with  inner  coat  of  artery ;  e,  vessels  of  thrombus  ;  /,  groups  of 
pigment  granules. 


misleading,  for  it  is  doubtful  if  direct  adhesion  of  the 
opposite  sides  of  the  intima  ever  takes  place.  The  cor- 
rect explanation  seems  to  be,  that  changes  occur  in  the 
clot  that  end  in  its  complete  organisation,  and  the  con- 
nective tissue  thus  formed  undergoing  cicatricial  con- 
traction and  blending  with  the  intima  of  the  vessel 
already   thickened    and    vascularised,    an    impervious 


chiap.  Lix.]  Thrombosis.  3r7 

cord  is  the  result.  When  a  clot  is  about  to  organise, 
the  red  corpuscles  disintegrate  and  the  colouring 
matter  set  free  is  in  great  part  absorbed.  Granules 
of  pigment,  however,  persist  for  a  long  time.  Leuco- 
cytes find  their  way  into  the  interior,  elongate,  ramify, 
and  anastomose.  The  fibrin,  according  to  some, 
degenerates  and  is  removed,  whilst  others  state  that 
it  fibrillates  and  helps  to  form  connective  tissue. 
Capillary  blood-vessels  develop  {vide  Organisation  of 
inflammatory  deposits)  and  join  the  main  channel 
and  also  the  vasa-vasorum  (Otto  Weber).  Fig.  50 
represents  a  section  of  a  carotid  artery  occupied  by 
young  vascular  connective  tissue.  The  case  was  one 
of  aortic  aneurism,  in  which  the  orifice  of  the  left 
carotid  was  closed.  Thrombosis  gradually  spread 
from  below  until  the  whole  vessel  was  occluded. 
Sections  at  different  levels  demonstrated  the  successive 
changes  from  recent  coagulation  to  complete  develop- 
ment of  fibrous  tissue.  According  to  Cornil  and 
Ranvier,  it  is  the  irritation  of  the  clot  that  sets  up  the 
endophlebitis,  which  consists  of  a  proliferation  of 
the  endothelium,  exudation  of  lymph  cells,  and  the 
formation  of  vessels  which  penetrate  the  thrombus  ; 
they  say  that  as  the  latter  is  absorbed  the  inflamed 
intima  fills  up  the  lumen  of  the  vein,  and  if  its  blood- 
vessels dilate  at  the  same  time  a  cavernous  tissue 
results,  but  as  a  rule  the  vein  is  permanently  obli- 
terated. 

Suppuration,  though  rare,  does  occur.  The 
leucocytes  are  derived  from  the  vasa-vasorum  of  the 
walls  of  the  vessel  softened  by  inflammation,  and 
possibly  also  from  the  blood  that  bathes  the  thrombus, 
whilst  many,  no  doubt,  collected  in  the  vessel  before 
coagulation.  The  migratory  corpuscles,  whatever  their 
source,  mingle  with  the  liquefied  debris  of  the  clot. 
The  pigment  of  the  disintegrated  corpuscles  gives  to 
the  whole  a  bufi*,  reddish-yellow,  or  chocolate  colour. 


31 8  Surgical  Pathology.  [Chap.  lix. 

CoELgfulation   toefore    a,nd    after    death. — 

Clots  formed  during  the  last  few  hours  of  life  in  the 
right  side  of  the  heart  and  pulmonary  artery,  and  in 
the  systemic  veins,  are  often  as  much  the  result  of 
dying  as  the  cause  of  death.  They  cannot  for  certain 
be  told  from  post-mortem  coagula,  since  sufficient  time 
has  not  elapsed  for  the  secondary  changes  to  have  set 
in.  In  both  cases  (unless  post-m,ortem,  coagulation  is 
very  rapid)  the  lower  portion  of  the  clot  is  deep  violet 
or  quite  black,  and  the  upper  of  a  pale  buff  or  yellow 
colour,  from  subsidence  of  the  red  corpuscles.  The 
whole  is  tough  and  elastic,  and  is  smooth  on  the 
surface  and  not  firmly  adherent  to  the  vessel  which 
contains  it :  in  fact,  it  never  completely  fills  the  vessel. 
Undoubted  ante-mortem  clots,  on  the  other  hand,  are 
more  brittle,  often  breaking  with  a  granular  fracture, 
are  more  uniformly  pale  from  decolorisation,  and  are 
for  the  most  part  adherent. 

The  difference  is  well  marked  where  an  old  softened 
venous  thrombus  has  been  detached  and  swept  into 
the  riofht  side  of  the  heart,  and  there  formed  the 
centre  of  fresh  coagulation. 

Ante-mortem  thrombi  are  composed  of  concentric 
laminse,  for  the  coagulum  first  filling  the  vessel  shrinks 
like  any  other  blood  clot,  and  thus  allows  a  lazy 
current  to  trickle  between  it  and  the  vessel  wall.  A 
succession  of  alternate  clottings  and  contractions  goes 
on  until  the  vein  is  finally  blocked. 

The  clots  always  contain  a  large  number  of  leuco- 
cytes, which  accumulate  in  the  vessel  during  the 
preliminary  stages  of  slowing  and  stasis. 

Dr.  Bastian  has  described  a  capillary  obstruction 
by  an  aggregation  of  white  corpuscles. 


319 


CHAPTER  LX. 

ACUTE    ORCHITIS    AND    EPIDIDYMITIS. 

Acute  inflammation  of  the  testis  maj  be  excited 
in  one  of  three  ways:  (1)  By  direct  irritation;  (2) 
by  metastasis ;  (3)  by  extension  of  the  process  from 
the  urethra  and  spermatic  cord. 

In  the  two  former  cases  the  body  of  the  testis  is 
usually  involved  before  the  epididymis.  With  regard 
to  metastasis  in  the  specific  disease,  "  mumps,"  it  is 
open  to  question  whether  the  orchitis  is  not  the  direct 
result  of  the  poison  of  the  fever,  rather  than  a  trans- 
ference of  inflammation  from  one  gland  to  another, 
and  between  which  there  is  no  developmental,  ana- 
tomical, nor  physiological  relationship.  The  fact  that 
orchitis  follows  in  the  wake  of  parotitis  is  no  proof 
that  it  is  the  consequence  of  it.  The  correct  pathology 
is  probably  explained  by  saying  that  the  poison  of 
mumps  has  a  much  less  affinity  for  the  testis  than  the 
parotid,  and  thus  afi'ects  it  more  rarely,  and  when  it 
does,  at  a  later  period. 

Orchitis,  follovnng  gonorrhcea^  is  in  most  instances 
the  result  of  spreading  of  the  inflammation  from  the 
urethra  along  the  vas  deferens  to  the  epididymis,  for 
the  cord  is  more  or  less  enlarged,  indurated,  and 
tender.  Its  late  occurrence  can  be  accounted  for  by 
the  time  taken  by  the  inflammatory  process  to  extend 
through  such  a  lengthy  tract,  and  the  simultaneous 
subsidence  of  the  urethritis  may  be  explained  by 
supposing  that  the  suddenly  developed  severe  affec- 
tion of  the  testis  acts  as  a  derivative  through  the 
functionally   associated    nerves.      The    last-mentioned 


320  Surgical  Pathology.  [Chap.  lx. 

circumstance  may,  however,  be  advanced  in  support 
of  the  theory  of  metastatic  inflammation. 

Blood  poisoning  rarely  leads  to  orchitis,  either 
by  way  of  embolism,  or  by  the  direct  action  of 
invisible  infective  matter  circulating  in  the  blood.  I 
have  once  seen  pysemic  suppuration  in  the  sac  of  an 
old  hydrocele  of  the  tunica  vaginalis. 

Gout  is  another  disease  that  occasionally  affects 
the  testis,  and  in  which  there  is  liability  to  recurrence 
of  the  inflammation. 

Orchitis  is  a  good  instance  of  exudation  beneath  a 
resisting  membrane.  This,  taken  with  the  natural 
sensibility  of  the  organ,  explains  the  severe  aching 
pain.  The  hyper-sensitive  nerves  are  compressed  by 
the  effusion  and  vascular  dilatation  on  the  one  hand, 
and  the  inelastic  fibrous  tunic  on  the  other. 

The  lymph  is  effused  first  between  and  then  into 
the  seminiferous  tubes.  The  epithelium  becomes 
swollen  and  granular,  and  its  cells  proliferate.  As 
the  inflammation  subsides  healthy  cells  replace  those 
cast  off,  the  same  as  in  desquamative  nephritis. 
Whilst  the  formative  activity  of  the  epithelium  is 
increased,  the  functional  power  is  diminished,  for  the 
cells  merely  reproduce  themselves,  instead  of  furnish- 
ing spermatic  filaments. 

In  some  cases,  especially  in  orchitis,  the  sequel  of 
mumps,  the  functional  power  is  permanently  lost,  and 
as  the  old  degenerated  cells  are  removed  by  absorption, 
the  whole  organ  atrophies.  This  must  be  partly 
attributed  to  the  specific  effects  of  the  poison  upon 
the  gland  epithelium,  in  the  same  way  that  the  hair 
follicles  and  papillae  sometimes  waste  after  the  exan- 
thematous  fevers,  causing  baldness.  This  explanation 
is  based  on  the  fact  that  the  intensity  of  the  inflam- 
mation is  no  certain  guide  to  the  final  result,  repair 
or  decay. 

As    the    inflammation    spreads  from  the    seminal 


Chap.  LXL]  Simple  Sarcocele.  .^2t 

tracts  to  the  surrounding  tissues,  it  causes  thickening 
of  the  cord,  oedema  of  the  scrotum,  and  acute 
hydrocele.  The  tunica  vaginalis  rarely  contains  more 
than  two  ounces  of  fluid,  usually  less.  The  fluid  is 
highly  fibrinous,  and  readily  coagulates  when  with- 
drawn, differing  in  this  way  from  that  of  simple 
chronic  hydrocele,  which,  though  rich  in  fibrinogen, 
does  not  often  gelatinise  spontaneously.  It  is  generally 
absorbed  as  the  orchitis  subsides.  By  far  the  most 
frequent  termination  of  orchitis  is  in  resolution.  Some- 
times the  inflammation  becomes  chronic  j  suppuration 
is  quite  the  exception. 


CHAPTER  LXL 

CHRONIC    ENLARGEMENTS    OF    THE    TESTICLE. 

These  are  designated  by  the  common  term  sar- 
cocele^ which  simply  means  a  fleshy  swelling.  Several 
distinct  aff'ections  are  embraced  by  the  definition, 
which  can  only  be  justified  by  long  usage. 

The  varieties  of  sarcocele  usually  enumerated  are: 
(1)  Simple  ;  (2)  syphilitic ;  (3)  scrofulous  and  tuber- 
cular ;  (4)  malignant;  (5)  cystic.  The  first  three  are 
essentially  inflammatory,  the  fourth,  with  few  excep- 
tions, includes  the  fifth. 

Simple  sarcocele  may  be  chronic  from  the  first, 
or  the  sequel  of  one  acute  or  several  subacute  attacks 
Anatomically  it  is  impossible  to  draw  a  hard  and  fast- 
line  between  it  and  the  milder  non-suppurative  forms 
of  strumous  testis. 

The  body  of  the  organ  is  uniformly  enlarged,  hard, 
and  not  very  tender  or  painful.  When  the  epididymis 
is  aflfected,  which  it  almost  invariably  is,  and  firmly 
adherent    to    the   testis  proper,    the   swelling  of  the 

V 


32  2  Surgical  Pathology,  [Chap.  lxi. 

globus  major  and  minor  may  give  a  nodulated  outline 
to  the  mass. 

There  may  be  some  jiuid  in  the  tunica  vaginalis, 
but  frequently  the  cavity  of  the  latter  is  obliterated. 
The  cord  is  somewhat  enlarged  from  dilatation  of  the 
vessels.  The  existence  and  amount  of  induration 
depend  to  a  great  extent  upon  whether  it  was  impli- 
cated or  not  by  the  original  inflammation. 

As  a  rule  only  one  testicle  is  affected,  but  when 
the  inflammation  is  set  up  and  perpetuated  by  the 
continued  irritation  from  a  stricture  of  the  urethra, 
both  may  be  involved. 

The  lymph,  instead  of  breaking  down  to  form  an 
-abscess  or  softening  cavity,  or  being  ab/sorbed,  organises 
ito  dense  fibrous  tissue.  The  cut  surface  presents  a 
greyish  semi-translacent  aspect,  with  perhaps  a  dash 
of  yellow,  from  fatty  degeneration  of  the  epithelium 
and  the  wandering  cells.  It  is  homogeneous,  or 
streaked  with  bands  of  connective  tissue.  The  micro- 
scopical appearances  vary  with  the  extent  and  duration 
of  the  inflammation.  When  the  disease  is  of  long 
standing  nothing  may  be  seen  but  an  imperfectly 
fibrillated  structure,  with  a  few  indiflerent  cells  and 
fat  granules  scattered  over  the  field.  Most  of  the 
blood-vessels  having  been  obliterated,  it  appears  almost 
extravascular,  unless  the  remaining  ones  be  shown  up 
by  artificial  injection. 

In  more  recent  cases  one  recognises  in  some  parts 
minute  clefts  or  alveoli  filled  with  granular  debris  and 
degenerated  cells;  but  there  is  no  regularity  of  disposi- 
tion, for  whilst  in  one  place  the  exudation  is  homo- 
geneous or  faintly  striated,  and  practically  devoid  of 
vessels  and  corpuscles,  in  another  it  is  more  vascular 
and  cellular. 

Sj^pliiliticsarcocele.— Tertiary  syphiliticdisease 
of  the  testis  presents  itself  under  two  forms  ;  diffuse 
orchitis  and  localised  gaimmy  tumour.      In  the  former 


Chap.  LXI.] 


SvPHiLiric  Sarcocele. 


323 


case  the  enlargement  of  the  organ  is  uniform,  and  the 
surface  consequently  remains  even.  In  the  latter, 
whilst  one  part  of  the  testis  retains  more  or  less 
its  natural  anatomical  features,  the  other  is  occupied 
by  a  hard  swelling,  which  projects  as  a  rounded  nodule, 
or  craggy  mass,  giving  an  irregular  outline  to  the 
swelling. 

Again,  the  exudation  may  in  the  first  instance  be 
confined  to  one  region,  and  afterwards  become  difi'used, 
showing  that  the  minute 
pathological  changes 
are  essentially  the  same 
in  both  cases.  In  the 
circumscribed  gum- 
matous mass  the  in- 
flammation may  be  said 
to  be  concentrated. 
The  vessels,  too,  are 
extensively  obliterated, 
by  pressure  of  the 
effusion  without,  and 
thrombosis  within. 
The  latter  process  is  en- 
hanced by  the  diseased 
condition  of  the  vascular 
walls,  which,  by  causing 
thickening  and  irregu- 
larity of  the  intima, 
diminishes  the  lumen 
and  obstructs  the  flow  of 
blood.  The  obliteration 
of  the  vessels,  coupled 
with  the  inherent  low 
vitality  of  the  exuded 
lymph,  explains  the  sub- 
sequent fatty  degenera- 
tion and  caseation. 


n^-e 


Fig.  51.— Syphilitic  Orchitis, 
a,  Vas  defei-ens;  6,  blood-vessels  distended 
with  gelatin  :  c,  small  s'ummatous  de- 
posit ;  d,  portion  of  epididymis ;  e,  inflam- 
matory thickening  of  tunics.  The  cord 
is  enlarged,  but  not  indurated.  The 
cavity  of  the  tunica  vaginalis  is  oblite- 
rated, except  at  the  upper  part  of  the 
testicle.  The  entire  organ  is  infiltratPd 
with  inflammatory  exudation,  but  the 
blood-vessels  are  still  everywhere  per- 
vious.   (Reduced  one  quarter.) 


324  Surgical  Pathology.  [Chap.LXi. 

Eig.  51  represents  a  testicle  removed  post  mortem 
from  the  body  of  a  man  who,  at  the  time  of  his  death 
by  accident,  was  the  subject  of  well-marked  tertiary 
syphilis.  The  vessels  have  been  injected  with  carmine 
and  gelatin.  In  the  centre  of  the  organ  is  a  rounded 
nodule  of  very  firm  consistence,  which  is  clearly  a 
gumma  in  process  of  development.  It  is  quite 
vascular,  but  from  its  induration  being  greater  than 
the  surrounding  tissue,  it  has  shrunk  less  by  the 
action  of  the  spirit  in  which  the  specimen  is  pre- 
served, and  is  consequently  raised  above  the  general 
section  surface.  The  entire  body  of  the  testis  is 
enlarged,  but  the  epididymis  is  not  appreciably 
afiected.  On  microscopical  examination  of  the  nodule, 
the  tubules  were  found  to  have  been  destroyed,  and 
replaced  by  vascular  inflammatory  neoplasia.  At  some 
distance  beyond,  the  tubules  could  still  be  recognised, 
imbedded  as  they  were  in  richly  corpuscular  exuda- 
tion, but  the  epithelium  had  lost  its  natural  characters. 
The  vessels  of  the  cord  are  enlarged,  but  they  are 
quite  distinct^  being  lightly  held  together  by  flocculent 
areolar  tissue ;  hence  there  is  no  induration.  There  is 
no  hydrocele.     The  other  testicle  was  quite  healthy. 

This  preparation  may  be  taken  as  being  fairly 
representative  of  syphilitic  orchitis,  diffuse  and  gum- 
matous. It  is  interesting  as  showing  the  vascularity 
of  a  gumma  in  the  early  stage  of  formation. 

Modes  ©f  terminatioii  of  sypSiilitic  orcliitis. 
— (1)  Under  treatment  resolution  is  very  common, 
the  function  of  the  gland  remaining.  (2)  If  left 
alone  the  exudation  may  become  indurated,  and 
organise  to  imperfectly  fibrillated  connective  tissue, 
but  it  more  frequently  undergoes  caseous  degenera- 
tion, especially  when  the  inflammation  is  of  the 
gummatous  variety.  Sometimes  the  degenerated 
products  of  a  gumma  are  partially  absorbed,  and  the 
remainder  encapsuled  by  dense  fibrous  tissue.     After 


Chap.  LXi.j  Syphilitic  Sarcocele.  325 

a  long  duration,  the  exudation  of  diffuse  orchitis, 
together  with  the  debris  of  the  secreting  structure, 
may  be  slowly  removed  by  the  vessels,  leaving  the 
gland  atrophied  and  firm.  (3)  Acute  suppuration  is 
rare,  chronic  much  less  so.  The  scrotal  tissues 
become  adherent  to  the  parts  beneath,  then  ulceration 
takes  place,  and  the  gummatous  material  disintegrates, 
and  escapes  with  the  jDurulent  secretion  around.  In 
patients  who  are  broken  down  in  health,  suppuration 
may  be  more  active,  and  isolate  the  caseous  mass, 
which  is  then  liberated,  and  cast  off  as  a  slough. 

Condition  of  tlie  tunica  vaginalis* — 
Hydrocele  is  frequent,  as  might  be  expected  from  the 
body  of  the  gland  being  so  commonly  the  seat  of  the 
disease  in  c[uestion.  The  fluid  resembles  the  secre- 
tion of  simple  irritative  dropsy  in  other  serous  mem- 
branes. On  being  drawn  it  may  remain  in  the  liquid 
state,  or  form  a  gelatinous  coagulum. 

The  surface  of  the  visceral  layer  of  the  tunica 
vaginalis  is  sometimes  irregular,  from  the  deposit  of 
nodules  of  lymph.  Unless  there  be  sufficient  fluid  to 
keep  the  visceral  and  parietal  layers  apart,  adhesion 
is  very  likely  to  take  place  between  them,  so  that  the 
ca^dty  is  partially  or  entirely  obliterated. 

State  of  the  cord. — The  vessels  are  dilated,  and 
in  long-standing  cases  their  walls  are  thickened ; 
but  the  exudation  is  rarely  sufficient  to  weld  them 
together  into  a  firm  indurated  mass. 

General  considerations.  —  Syphilitic  sarcocele, 
whether  diffuse  or  gummatous,  is  characteristic  of 
the  tertiary  stage  of  the  disease.  Both  testicles 
may  be  affected,  but  very  frequently  only  one  is 
involved.  The  deposit  rarely  begins  in  the  epidi- 
dymis, and  when  it  does  the  cord  is  much  more  likely 
to  remain  free  from  induration  than  in  strumous  testis. 
As  a  rvile  the  inflammation  is  very  amenable  to 
specific  treatment. 


326  Surgical  Pathology.  [Chap.  lxi. 

Scrofulous  sarcocele. — As  in  scrofulous  disease 
of  other  tissues,  the  inflammation  here  shows  itself  in 
the  form  of  diffuse  exudation,  or  as  isolated  and  con- 
fluent miliary  tubercles  or  granulations,  or  as  a  com- 
bination of  the  two  varieties.  Some  pathologists  look 
upon  the  expressions,  "scrofulous"  and  "tubercular 
testis,"  as  synonymous  ;  regarding  the  nature  of  the 
disease  in  its  general  aspects  as  scrofulous,  and  the 
morbid  products  as  tubercular,  whether  they  assume 
the  discrete  or  diffuse  form.  Others,  who  recognise 
in  disseminated  tubercle  the  evidence  of  infection 
from  a  pre-existing  caseous  focus,  consider  that  they 
should  be  described  apart.  But  since  the  two  varieties 
are  frequently  associated,  and  they  both  arise  under 
like  conditions  of  general  health,  and  have  a  special 
tendency  to  attack  the  epididymis  rather  than  the  body 
of  the  testis,  there  are  good  reasons  for  maintaining 
their  close  relationship,  if  not  their  etiological  identity. 

Still,  on  anatomical  grounds  it  is  convenient  to 
describe  them  separately. 

I>ilfu<i)e  strumous  orcliitis  and  epididymitis 
is  usually  found  in  patients  who  have  a  family  or 
personal  history  of  phthisis,  or  other  manifestations 
of  the  strumous  diathesis.  There  is  a  great  liability 
for  both  testicles  to  be  affected,  though  months  or 
years  may  intervene  between  the  periods  of  accession 
of  the  inflammation  in  the  two  organs. 

In  the  majority  of  cases  the  disease  commences  in 
the  epididymis,  and  for  a  long  time  it  may  be  confined 
to  that  situation ;  but  sooner  or  later  the  testis  itself 
is  usually  involved.  Instead  of  uniform  swelling,  the 
outline  of  the  tumour  is  very  irregular  and  nodular. 
The  spermatic  cord  is  thickened.  On  examination 
per  rectum  the  vesiculse  seminales  may  be  found  to 
be  free,  or  indurated  and  enlarged  (Fig.  55,  c).  After 
a  time  the  scrotum  becomes  congested,  (edematous, 
and  adherent  to  the  structures  beneath. 


Chap.  LXi.]  Hernia   Testis.  327 

The  further  course  is  uncertain.  Under  treatment 
the  inflammation  may  subside,  leaving  a  nodular  hard- 
ness in  the  epididymis,  to  which,  the  scrotum  remains 
fixed  by  puckered  adhesions.  But  the  tendency  is  to 
caseation  and  chronic  abscess.  The  whole  organ  may 
be  converted  into  a  cheesy  mass  without  suppuration 
occurring ;  but  as  a  rule  the  degenerated  tissue  breaks 
down,  and  the  debris  mingles  with  the  exudation 
from  the  surrounding  vessels.  Then  fluctuation  can 
be  detected,  and  little  by  little  the  integument  thins,, 
and  finally  it  bursts,  and  the  contents  of  the  cavity 
are  evacuated. 

Before  this  happens  the  whole  of  the  secreting 
structure  may  be  destroyed,  but  far  "more  commonly 
the  abscess  points  and  opens  whilst  it  is  yet  localised. 
The  lining  wall  is  covered  on  the  free  surface  with; 
pus  and  disintegrating  tissue  j  next  to  this  is  a  belt  ol 
vascular  granulation  tissue. 

From  this  point  the  disease  may  take  one  of  two> 
departures  :  (1)  Filling  in  of  the  cavity  with  lymph 
that  organises  and  cicatrises,  ^.e.,  spontaneous  cure;. 
(2)  progressive  suppuration,  and  destruction  of  the 
remaining  portion  of  the  gland.  The  former  is  the 
exception.     The  latter  in  its  progress  develops 

Hernia  testis — fiuig'oiis  testis,  like  hernia 
cerebri,  is  essentially  inflammatory.  The  mere  open- 
ing in  the  tunica  albuginea  does  not  explain  it ; 
if  it  did,  this  would  be  sufiicient  ground  alone  to 
centra-indicate  the  treatment  of  acute  orchitis  by 
puncture.  Nevertheless,  the  resistance  offered  by  the 
unyielding  fibrous  capsule  is  an  important  factor  in 
the  process,  for  whilst  the  volume  of  the  contents 
tends  continuously  to  increase,  by  reason  of  the  exu- 
dation from  the  vessels,  accumulation  is  prevented  by 
the  rigidity  of  the  inexpansile  investment  of  the 
organ.  Hence  it  follows  that  so  long  as  exudation 
exceeds  absorption  the  surplus  must  escape  through 


o 


28  Surgical  Pathology.  [Chap.  l.xi. 


the  opening  established  by  the  bursting  of  the 
abscess. 

But  it  is  not  simply  a  filtering  of  pus  through  the 
inflamed  tissue,  since  this  would  not  account  for  the 
protrusion.  Fibrin  separates  from  the  liquor  sanguinis 
and  imbeds  the  migratory  leucocytes  ;  and  into  the 
semi-solid  product  capillary  loops  shoot  from  the 
adjacent  vessels  ;  and  thus  a  vascular  granulation 
tissue  is,  formed  which  constitutes  the  greater  part  of 
the  fungus. 

Meanwhile  the  glandular  tubules  are  broken  up, 
but  before  their  disintegration  is  complete,  columns 
and  isolated  cells  of  epithelium  are  carried  outwards 
by  the  advancing  granulation  tissue  with  which  they 
are  incorporated,  and  can  be  recognised  with  the 
microscope.  The  fungus  does  not  attain  a  large  size, 
for  the  superficial  layer  melts  away  whilst  the  growth 
is  replenished  from  beneath.  After  a  time  it  becomes 
stationary,  and  with  the  subsidence  of  the  inflamma- 
tion it  recedes.  The  secretion  is  at  first  purulent,  then 
muco-purulent,  or  thin  and  serous.  Its  nature  and 
quantity  depend  upon  the  degree  of  inflammation. 
The  skin  around  is  congested,  and  in  long-standing 
cases  the  papillae  and  hairs  are  hypertrophied. 

There  is  a  milder  form  of  "  fungous  testis,"  in 
which  the  glandular  structure  seems  to  be  but  little, 
if  at  all,  afiected.  A  small  abscess  forms  beneath 
the  scrotuui,  and  opens  externally.  This  leaves  a 
sinus,  terminating  in  an  orifice  surrounded  by  pale 
gelatinous  granulations.  On  manipulation  an  indu- 
rated cord  can  be  felt,  taking  ih.Q  direction  of  the 
sinus,  and  fixed  to  the  testis  or  epididymis.  It  pro- 
bably begins  as  a  localised  infiammation  in  the  tunica 
vaginalis,  and  in  that  case  it  is  comparable  to  a  sup- 
purating sebaceous  cyst. 

Section  of  a  striimoiis  testis. — The  appear- 
ance on  section  will  depend  upon  the  rate  at  which  the 


Chap.  LXL] 


Scrofulous  Sarcocele. 


329 


structure  has  been  undermined,  and  the  time  at  which 
the  examination  is  made.  In  comparatively  acute 
cases  the  whole  organ  may  be  broken  down  into  a 
semi-diffluent   pulp ;    suppuration   having    completed 


Fi^.  52. — Scrofulous  Orchitis,  showing  the  Formation  of  Abscess. 
The  preparation  was  injected  with  Gelatin  and  Prussian-blue. 

a.  Spermatic  cord  much  enlarged,  the  vessels  are  embedded  in  indurated 
lymph;  &,  portions  of  the  testicle  apparently  quite  healthy,  the  tubules  are 
seen  presenting  a  fringed  appearance  on  the  surface  of  the  section;  c,  irre- 
gular mass  of  cheesy  matcri'il,  the  nrtificial  injection  has  stopped  alirujitly 
at  the  periphery ;  rV,  small  abscess  pointing  at  the  front  of  the  organ.  The 
epididymis,  which  hns  lost  its  outline,  forms  a  solid  mass  at  the  upper  and 
back  parts  of  the  testis,  continuous  with  the  thickened  cord.  (E.educed  one 
quarter.) 

the  destruction  begun  and  continued  by  gradual  obli^ 
teration  of  the  vessels  and  consequent  fatty  degene- 
ration. 

But  the  testis  undergoes  considerable  enlargement, 
and  caseation  is  for  the  most  part  well  advanced 
before   the  occurrence  of  suppuration.     Large  tracts 


330  Surgical  Pathology.  [Chap.  lxi. 

ai-e  slowly  deprived  of  tlieir  vascular  supply,  and  the 
constituent  elements  break  up  into  molecular  fat. 
Meanwhile  a  gradual  desiccation  takes  place,  with  the 
result  that  the  disorganised  tissue  and  exudation  are 
left  as  irregular  firm  cheesy  masses,  which  appear 
granular  or  quite  smooth  on  the  cut  surface.  Artificial 
injection  shows  these  masses  to  be  entirely  free  from 
the  circulation,  and  makes  them  stand  out  in  marked 
contrast  to  the  surrounding  tissue,  which  is  coloured 
by  the  fluid  that  finds  its  way  into  the  as  yet  patent 
vessels. 

Mg.  52  represents  a  strumous  testis  removed  from 
a  man  cet.  30.  The  other  gland  had  been  excised 
three  and  a  half  years  before  for  the  same  disease. 
The  cord  is  thickened.  A  portion  of  the  secreting 
structure  appears  healthy.  There  is  a  yellowish- 
white  caseous  mass  at  the  centre  and  to  one  side. 
Suppuration  has  commenced,  and  already  destroyed 
the  investing  tunics,  and  caused  the  skin  to  bulge. 
During  life  fluctuation  could  be  detected  at  this  spot. 

Minute  anatomy  of  scrofulous  sarcoeele. 
— It  was  formerly  supposed  that  the  disease  began 
as  an  inflammatory  effusion  into  the  tubuli  seminiferi, 
and  that  as  the  walls  of  the  latter  became  softened 
and  distended,  they  ruptured  and  discharged  their 
contents  into  the  intertubular  spaces.  But  this 
is  not  the  case.  The  essential  pathology  is  a 
chronic  interstitial  orchitis  (JFig.  15).  The  con- 
nective tissue  is  increased  by  infiltration  with  liquor 
sanguinis  and  leucocytes.  This  may  be  very  decided 
before  there  is  any  change  in  the  epithelial  lining  of 
the  tubes.  After  a  time,  however,  the  cells  become 
granular,  and,  as  they  proliferate,  are  set  free  in  the 
lumen,  which  eventually  becomes  choked  with  de- 
squamative and  exudation  products.  The  morbid 
processes  can  be  studied  better  in  the  epididymis  than 
in  the  testis  proper,  for  in  it  the  tubes  are  much  wider. 


Chap.  LXL]  Tubercular  Orchitis.  331 

The  blood-vessels  get  blocked  by  coagula  and  com- 
pressed by  exudation.  The  result  of  this  is  a  starva- 
tion of  the  tissues  they  supply,  and,  as  a  natural 
consequence,  fatty  degeneration  and  caseation.  Or 
the  interruption  in  nutrition  may  be  more  acute,  as 
the  effusion  from  the  vessels  is  more  rapid  and  copious. 
Then,  instead  of  caseating,  the  neoplasia  liquefies,  and 
suppuration  is  established.  On  the  other  hand,  the 
lymph  may  organise  into  a  low  form  of  cicatricial 
tissue.  Bearino:  these  facts  in  mind  we  can  understand 
the  diversified  appearances  in  the  group  of  cases 
designated  strumous  testis. 

Disseminatecl  tubercular  orchitis.  —  This 
variety  of  strumous  testis  is  generally  seen  in  the 
course  of  a  more  wide-spread  miliary  tuberculosis, 
particularly  through  the  genito-urinary  tract.  Even 
when  the  disease  appears  to  be  localised  in  the  testis 
there  is  great  liability  to  its  subsequent  outbreak  in 
other  organs.  I  have  known  tubercular  meningitis 
follow  disseminated  tubercle  of  the  testis  in  the 
adult.  Fig.  55  depicts  the  bladder  of  a  patient 
who  had  tubercular  ulcers  of  the  urethra,  and  in 
whom  the  kidneys,  prostate,  vesiculse  seminales,  and 
vasa  deferentia  were  affected  with  caseating  miliary 
granulations.  But  it  must  be  remembered  that  the 
diffuse  strumous  orchitis  before  described  is  also  prone 
to  set  up  or  be  followed  by  true  tubercular  deposit  in 
the  same  organ,  or  in  distant  parts ;  and  that  chronic 
strumous  inflammation  is  excited  by  the  presence  of 
tubercles.  The  so-called  strumous,  and  tubercular 
orchitis  are  strictly  analogous  to  strumous,  and 
tubercular  ostitis  {q.v^. 

Anatomically  the  disease  is  characterised  by  the 
development  of  grey  granulations  between  the  tubules 
of  the  epididymis  and  testis.  At  first  they  are  dis- 
crete, but  subsequently  they  become  more  or  less  con- 
fluent by  their  own  growth ;  or  by  the  intercalation 


332  Surgical  Pathology.  [Chap.  lxi. 

of  fresh,  tubercules ;  or  a  number  of  granulations 
may  be  hidden  in  the  exudation  products  of  in- 
flammation between  and  around  them.  They  soon 
undergo  fatty  degeneration  and  caseation,  and  as 
they  soften  in  the  centre  small  abscesses  are  formed; 
by  the  aggTegation  and  fusion  of  these  abscesses 
irregular  cavities  with,  festooned  margins  are  made. 

Miliary  tuberculosis  of  the  testis  is  more  common 
than  is  generally  supposed,  as  the  patients  frequently 
die  from  the  invasion  of  the  more  vital  organs  before 
the  local  lesion  is  sufficiently  advanced  to  be  recognised 
during  life.  Both  testicles  are  u,sually  involved,  and 
the  vasa  deferentia  and  vesiculae  seminales  appreciably 
thickened  (Fig.  55). 

The  inflammatory  changes  set  up  around  the 
tubercles  differ  in  no  way  from  what  is  observed  in 
primary  diffuse  strumous  orchitis. 

The  usual  characters  of  grey  granulations  can  be 
demonstrated :  viz.,  a  delicate  reticulum  of  homogeneous 
or  finely  fibrillated  intercellular  substance  enclosing 
lymph  corpuscles  and  giant  cells. 

Malignant  sarcocele, — Malignant  disease  of 
the  testicle  includes  encephaloid  cancer,  sarcoma,  and 
enchondroma.     Colloid  cancer  is  very  rare. 

The  features  that  serve  to  distinguish  new 
growths  involving  the  testicle  from  inflammatory 
enlargements  are  as  follows  ; — 

1.  Size.  This  may  be  quite  decisive,  for  whilst  a 
tumour  may  exceed  in  size  the  foetal  head  at  full 
term,  simple,  syphilitic,  and  strumous  sarcocele  rarely 
attain  a  gTeater  magnitude  than  a  goose's  ^gg. 

2.  Lobulation.  Malignant  growths  are  not  un- 
commonly lobulated,  not  so  much  on  the  surface  as 
in  their  internal  structure,  for  the  resistance  offered 
by  the  tunica  albuginea  serves  to  difluse  the  pressure 
and  maintain  the  even  outline  of  the  mass.  The 
caseous  patches  of    strumous   orchitis    and    syphilitic 


Chap.  LXL]       Cancer  of  the  Testicle.  333 

gummata  are  irregular  in  shape,  and  contrast  strongly 
with  the  surrounding  tissue. 

3.  Smooth-walled  cysts  are  quite  characteristic  of 
new  growth.  Thev  cannot  be  mistaken  for  the  cavities 
formed  by  softening  and  suppuration  in  strumous 
disease. 

4.  Malignant  tumours  that  are  very  rapid  in  their 
development,  especially  encephaloid  cancer,  often 
appear  fiocculent  on  the  cut  surface  when  the  pre- 
paration is  placed  in  fluid.  Inflammatory  deposits, 
on  the  other  hand,  are  generally  quite  smooth  on 
section. 

5.  As  malignant  growths  are  plentifully  supplied 
with  blood-vessels,  injections  of  coloured  jluid  pene- 
trate the  entire  mass.  The  yellow  caseous  tracts  of 
strumous  orchitis  and  syphilitic  gummata  are  ex- 
travascular,  and  consequently  the  injection  stops 
short  at  their  periphery. 

Whilst  one  or  more  of  the  above-mentioned  cri- 
teria may  fail  in  a  given  case,  the  evidence  afforded 
by  their  collective  consideration  can  never  leave  a 
doubt  as  to  the  nature  of  the  enlargement. 

Enceplialoid  cancer  is  usually  met  with  be- 
tween the  as;es  of  twenty  -  five  and  fortv  -  five.  It 
commences  in  a  proliferation  of  the  epithelium  of  the 
seminiferous  tubes.  The  growth  is  generally  very 
rapid.  The  whole  of  the  secreting  stiTicture  is 
destroyed  before  the  tunica  albuginea  gives  way. 
When  this  takes  place  the  scrotal  tissues  are  quickly 
involved  J  and  the  skin,  at  first  simply  adherent,  gets 
deeply  congested,  and  finally  it  ulcerates,  and  the 
unrestrained  growth  protrudes  as  a  bleeding  fungus, 
'■'■fungus  hcew.atodes.^'' 

The  uniform  elasticity  of  the  tumour  goes  a 
long  way  in  differentiating  it  from  strumous  and 
syphilitic  orchitis.  On  puncture,  blood  escapes  quite 
freely,  sometimes    bringing  with   it  minute  portions 


334 


Surgical  Pathology. 


[Chap.  LXI. 


of  growth,  the  structure  of  which  can  be  recognised 
under  the  microscope. 

Cysts   and    nodules    of    cartilage   are   much   less 
frequent  than  in  sarcoma. 


rt 


Fig.  53. — Chondro-sarcoma  of  the  Testicle. 

The  normal  structure  has  entirely  disappeared.  The  new  growth,  a,  presents  a 
regular  iobulated  appearance.  At  c  several  small  smooth-walled  mucous 
cysts  are  seen.  With  the  exception  of  the  nodule  h  the  cartilage  is  disposed 
in  microscopical  islets  in  the  substance  of  the  softer  sarcomatous  hase ;  /, 
caseous  dehris  of  inflammatory  exudation  in  upper  part  of  tunica  vaginalis  ; 
«, blood-vessels  filled  with  artificial  injection;  d,  spermatic  cord  enlarged, 
but  free  from  invasion  by  the  growth.    (Reducedone  quarter.) 


The  spermatic  cord  is  always  enlarged  by  dilata- 
tion of  the  blood-vessels  to  meet  the  wants  of  the 
rapidly-growing  mass.  It  may  also  be  indurated  by 
the  deposit  of  cancer  in  the  lymphatics  ;  but  this  I 
have  found  to  be  the  exception  rather  than  the  rule. 
^   If  the  glands  are  affected,  they  will  be  found  to 


Chap.  Lxi.]  Cystic  Sarcocele.  335 

be  the  lumbar  in  connection  with  the  testicle.  As 
the  integument  becomes  involved,  those  in  the  groin 
may  suffer  as  well. 

Except  in  very  rare  cases,  the  disease  attacks 
only  one  testicle.  For  an  account  of  the  naked-eye 
and  microscopical  characters,  vide  Encephaloid  cancer. 

Sarcoma,  occurs  at  the  same  period  of  life  as 
cancer,  but  it  is  also  met  with  in  children  under  ten 
years  of  age.  It  begins  in  the  connective  tissue  of 
the  gland  or  in  the  tunica  albuginea.  I  have  known 
it  attain  a  large  size  without  invading  the  testicle  at 
all,  but  this  is  very  unusual.  In  clinical  gravity  it 
Ades  with  cancer.  It  has  a  great  tendency  to 
generalise  in  the  internal  organs.  The  cord  and 
lymphatic  glands  are  sometimes  infiltrated. 

It  is  very  frequently  cystic.  Its  minute  struc- 
ture varies  between  round,  mixed,  and  spindle  cells. 
Cartilaginous  transformation  is  not  rare  (Fig.  53). 

Hiicliondroma  is  rather  a  chondrifying  sar- 
coma than  a  primary  cartilage  growth.  The  greater 
portion  of  the  neoplasia  may  be  converted  into 
cartilage.  In  such  a  case  the  term  enchondroma  is 
admissible  on  anatomical  grounds,  but  its  affinities 
with  sarcoma  should  never  be  lost  sight  of.  The 
cartilage  may  exist  in  the  form  of  microscopical  islets 
or  in  large  sinuous  tracts  or  clumps.  On  hardening 
these  tumours  in  spirit  the  cartilage  contracts  less 
than  the  surrounding  soft  sarcomatous  tissue,  and 
thus  the  cut  surface  is  rendered  uneven.  Secondary 
growths  in  the  internal  organs  retain  the  characters 
of  the  primary. 

The  cartilage  is  mostly  of  the  hyaline  variety. 

In  these  tumours  there  is  sometimes  a  considerable 
amount  of  gelatinous  or  mucoid  tissue. 

Cystic  sarcocele. — It  would  appear  that  some 
cases  of  cystic  testicle  are  developed  from  constriction 
and  dilatation  of  the  seminiferous   tubes  of  the  rete 


336  Surgical  Pathology.  [Chap.  lxi. 

testis  and  the  body  of  the  organ.  The  large  majority- 
are,  however,  not  of  this  nature,  but  are  dependent 
upon  mucoid  or  colloid  degeneration  of  the  cells  and 
intercellular  substance  of  some  pre-existing  solid 
growth. 

The  presence  of  a  number  of  cysts  in  a  tumour  of 
the  testis  at  once  raises  the  presumption  of  its  sarco- 
matous structure,  for  experience  shows  that  here,  as 
in  all  other  situations,  cystic  sarcoma  is  of  much  more 
frequent  occurrence  than  cystic  cancer. 

The  entire  mass  may  be  riddled  with  small  cysts, 
many  of  which  are  of  microscopical  dimensions,  im- 
bedded in  a  soft  greyish-white  ground  substance ; 
or  the  cysts  may  be  of  large  size,  and  so  numerous  as 
to  give  a  honeycombed  appearance  on  section.  The 
walls  of  the  cysts  are  for  the  most  part  quite  smooth, 
and  the  contents  clear,  and  either  pale  or  stained  with 
the  colouring  matter  of  the  blood  from  minute 
capillary  haemorrhages.  Other  cavities  or  accidental 
cysts  owe  their  origin  to  interstitial  extravasations 
and  fatty  softening  from  deficient  vascular  supply. 

Secondary  intracystic  growths  sometimes  partially 
or  entirely  fill  the  spaces.  In  the  latter  event  the 
nature  of  affairs  is  manifest  from  the  absence  of 
structural  continuity,  except  at  the  base  of  attach- 
ment, between  the  proliferating  buds  and  the  inner 
surface  of  the  walls  of  the  cysts. 

When  the  tumour  is  of  slow  growth  the  neoplasia 
passes  to  a  higher  phase  of  organisation,  so  that  the 
intercystic  trabeculae  appear  quite  fibrous. 


337 


CHAPTER    LXIL 

ATROPHY    OF    THE    TESTICLE. 

Smallness  of  a  testicle  does  not  necessarily  imply 
atrophy.  It  may  he  a  case  of  imperfect  development. 
Undescended  testicles  are  below  the  normal  size, 
whether  they  occupy  the  inguinal  canal  or  remain  in 
the  abdomen  free  from  unusual  pressure.  It  is  true 
the  resistance  offered  by  the  walls  of  the  canal  may 
hinder  the  growth  of  the  organ,  but  defective  develop- 
ment is  rather  the  cause  than  the  consequence  of 
arrested  descent. 

The  causes  of  atrophy  are  (1)  inflammatory  lesions  ; 
(2)  excessive  functional  activity;  (3)  senile  decay; 
(4)  long-standing  varicocele,  by  preventing  the  re- 
newal of  a  proper  amount  of  nutritive  fluid,  and  by  the 
continuous  pressure  of  the  distended  vessels  upon  the 
tubules ;  atrophy  from  this  source  never  amounts  to 
impotence  (Paget). 


CHAPTER    LXIII. 

HYDROCELE. 

The  term  hydrocele  is  applied  to,  for  the  most 
part,  watery  or  serous  exudations  into  (1)  the  tunica 
vaginalis  testis ;  (2)  the  whole  or  some  part  of  the 
funicular  portion  of  the  processus  vaginalis  peritonei  ; 
(3)  dilated  tubes  of  the  epididymis  or  rete  testis,  or 
the  hydatid  of  Morgagni,  or  the  vas  aberrans  of 
Haller;  (4)  loculi  in  the  spermatic  cord,  which  are 
w 


33^  Surgical  Pathology.        [Chap.  lxiii. 

said  to  correspond  to  free  cystic  formations  in  the 
cellular  tissue  of  other  parts. 

Hydi'ocele    of    tlie   tunica    vaginalis. — So 

far  as  one  can  tell,  this  often  constitutes  a  disease 
per  se,  i.e.,  it  arises  without  any  precedent  morbid 
condition  of  the  testicle.  In  such  cases  it  is  gene- 
rally found  at  the  two  extremes  of  life,  infancy 
and  old  age.  In  the  former  period  it  seems  to 
originate  in  the  locking  np  of  peritoneal  fluid  in  the 
tunica  vaginalis,  as  this  is  shut  off  from  the  funicular 
process  by  the  physiological  closure  of  the  canal  at 
the  top  of  the  testicle.  The  tension  upon  the  mem- 
brane jDrobably  stimulates  it  to  further  secretion,  for 
simple  withdrawal  of  the  contents  is  usually  sufficient 
to  effect  a  cure. 

The  hydrocele  of  old  people  is  said  to  be  the 
result  of  degenerative  changes  in  the  tunica  vaginalis, 
which  shows  itself  in  a  "  loss  of  balance  between 
secretion  and  absorption."  It  is  due,  then,  either  to 
hypersecretion,  or  to  obstruction  of  the  lymph  vessels 
that  naturally  carry  off  the  fluid  from  the  serous  sac ; 
or  it  may  to  some  extent  be  compensatory  to  the 
atrophy  of  the  testicle  incidental  to  advanced  age,  in 
the  same  way  that  fat  fills  up  the  spaces  of  wasting 
bone  and  serous  effusion  takes  the  place  of  a  shrinking 
brain. 

The  nature  of  the  Jluid  is  primarily  that  of  the 
normal  secretion  of  serous  membranes,  though  it  is 
frequently  modified  by  secondary  changes  consequent 
on  increased  irritation,  and  more  rarely  by  the  acci- 
dental rupture  of  blood-vessels  into  the  sac.  As  a 
rule,  it  is  quite  clear  and  straw-coloured.  It  contains 
a  considerable  amount  of  fibrinogen.  It  is  albumi- 
nous, as  shown  by  coagulation  by  heat  or  nitric  acid. 
Occasionally  it  holds  in  suspension  numerous  crystals 
of  cliolesterine,  the  product  of  fatty  metamorphosis. 
These    may    be    so    plentiful  as    to    cause    the   fluid 


Chap.  LXIII.] 


Hydrocele. 


to  sparkle  when  it  is  viewed  by  transmitted  light. 
Granules  and  crystals  of  hsematoidin  are  of  rarer 
occurrence ;  they  are  the  permanent  evidence  of 
previous  efifusion  of  blood. 

Condition    of  the   sac.  —  The    walls    are    nsually 
thin  enough  to  allow  of  translucency  of  the  swelling. 


Fig.  54. — Encysted  Hydrocele  of  the  Epididymis. 

a,  Cavity  of  tunica  vaginalis ;  b,  testicle  ;  c,  liydrocele  ;  d,  spermatic  cord. 
(Reduced  one  quarter.) 

In  some  cases  they  are  much  thickened  and  indurated, 
especially  after  repeated  tappings.  The  inner  surface 
is  smooth,  or  exceptionally  irregular  from  chronic  in- 
flammatory exudation. 

Vaginal  hydrocele  is  often  secondary  to  disease  of 
the  testicle,  especially  orchitis  {q.v.). 

The  measures  taken  to  obtain  a  cure  of  simple 
chronic  hydrocele  aim  at  obliteration  of  the  cavity 
by  inflammatory  adhesion,  or  by  such  alteration  of 
the    secreting    surface    as   entails  a  cessation  of   the 


340  Surgical  Pathology.        [Chap. lxiii. 

abnormal  effusion.  An  analogous  process  is  that  set 
up  by  injection  of  iodine  into  joints  the  seat  of 
hydrops  or  chronic  serous  synovitis. 

In  all  cases  of  acute  inflammatory  hydrocele  the 
fluid  is  highly  fibrinous. 

Encysted  Hydrocele  of  the  Epididymis. 

This  is  most  commonly  the  result  of  obstruction 
and  subsequent  dilatation  of  oue  of  the  vasa  efFerentia. 
Now  and  then  it  consists  of  an  enlargement  of  the 
vas  aberrans.  It  may  be  simulated  by  distension  of 
the  organ  of  Morgagni,  or  encysted  hydrocele  of  the 
contiguous  part  of  the  spermatic  cord.  In  the  first 
instance  it  is  situate  above  the  testicle,  but  as  it 
increases  in  size  it  invaginates  the  tunica  vaginalis, 
the  cavity  of  which  it  may  entirely  fill  (Eig.  54). 

The  contents  are  either  clear  and  serous  or  semi- 
opaque  and  opalescent,  like  water  rendered  slightly 
turbid  from  admixture  with  milk.  In  the  latter  case 
spermatic  filaments  are  present  in  abundance,  and  the 
tumour  is  known  as  ^^  sperriiatocele.^^  According  to 
Curling,  the  fluid  is  of  this  nature  from  the  commence- 
ment, or  what  was  originally  limpid  has  become 
cloudy  from  rupture  of  a  seminal  tubule  into  the  sac 
of  the  hydrocele. 

Congenital  Hydrocele. 

Here  the  process  of  peritoneum  brought  down  with 
the  descent  of  the  testicle  remains  patent  throughout, 
and  the  passage  opens  into  the  abdominal  cavity  by  a 
smaller  or  larger  orifice.  Reduction  of  the  fluid  is 
usually  quite  easy,  but  some  part  of  the  tract  may 
be  so  narrowed  that  continued  pressure  is  required  to 
effect  it. 

Hydrocele  of  the  Cord. 

Hydrocele  of  the  cord  is  either  encysted,  or  diffuse. 
Encysted     hydrocele    is    due    to    incomplete    closure 


Chap.  LXIV.]  GONORRHCEA,  341 

of  the  funicular  process  of  tlie  peritoneum.  Wliem 
very  tense,  and  occupying  the  inguinal  canal,  it 
may  be  mistaken  for  an  enlarged  gland. 

Diffuse  funicular  hydrocele  is  reducible  or  irre- 
ducible. In  the  former  case  the  continuity  of  the 
funicular  and  vaginal  sections  of  the  serous  tube  is 
broken  by  adhesion  of  the  opposed  surfaces  of  the 
membrane  above  the  testicle,  but  the  communication 
with  the  general  peritoneal  cavity  is  maintained.  In 
the  irreducible  variety  this  also  is  closed,  so  that 
there  is  an  isolated  sac  co-extensive  with  the  whole  or 
greater  part  of  the  cord.  Instead  of  one  space,  there 
may  be  a  series  of  encysted  hydroceles,  giving  a 
moniliform  appearance.  Some  authors  describe  an- 
other form  of  diffuse  hydrocele,  in  which  the  fluid  is 
said  to  distend  the  hollows  of  the  areolar  meshwork  of 
the  cord  ;  a  local  cedema,  in  fact.  The  cause  of  this  is 
difficult  to  understand,  for  there  are  none  of  the  other 
signs  of  inflammation  present,  and  simple  mechanical 
congestive  exudation  would  probably  be  associated 
with  varicocele,  a  condition  by  no  means  constant. 

The  walls  of  funicular  hydroceles  are  thin,  and  the 
fluid  the  same  in  kind  as  in  simple  vaginal  hydro- 
cele. 


CHAPTER    LXIV. 

GONORRHCEA    AND    ITS    CONSEQUENCES. 

Creneral  pathology.  —  Some  pathologists  be- 
lieve that  gonorrhoea  is  a  specific  disease,  whilst  others 
deny  it  this  attribute,  and  maintain  that  it  is  merely 
a  purulent  urethritis  capable  of  being  set  up  by 
other  conditions  than  impure  intercourse.  Abuse  of 
alcohol  and  excessive  indulgence  of  the  sexual  orgasm 


342  Surgical  Pathology.        [Chap.  lxiv. 

are  deemed  sufficient  for  its  causation.  Certain 
vaginal  discharges,  concerning  which  there  is  no 
reason  to  suppose  a  specific  origin,  not  unfrequently 
excite  acute  and  subacute  catarrhal  inflammation ; 
such,  e.g.^  are  the  products  of  leucorrhoea  and  menstru- 
ation. The  fact  that  the  disease  is  contagious  does 
not  prove  that  it  is  specific^  for  the  chemical  bodies 
formed  in  unhealthy  inflammations  have  a  cauterant 
action  on  the  tissues.  Moreover,  constitutional  infec- 
tion is  the  chief  sign  of  a  specific  disease,  and  in  the 
great  majority  of  cases  gonorrhoea  is  a  purely  local 
disorder.  Even  when  constitutional  symptoms  do 
manifest  themselves,  they  are  not  pathognomic  of 
specific  infective  inflammation,  for  simple  idiopathic 
suppuration  in  other  parts  is  known  to  cause  them 
in  certain  subjects. 

Morbid  aoatomy. — Gonorrhoea,  like  acute  in- 
flammation of  other  mucous  membranes,  first  shows 
itself  in  increased  secretion  of  mucus,  -i.e.,  in  unusual 
nutritive  and  functional  activity  of  the  epithelial  cells. 
But  soon  the  exudation  of  leucocytes  becomes  very 
active,  and  the  migratory  cells  mingle  with  embryonic 
corpuscles  derived  from  segmentation  and  endogenous 
multiplication  of  the  epithelium.  Pus  is  freely 
poured  out.  The  submucous  tissue  is  infiltrated  with 
liquor  sanguinis  and  cells,  and  the  membrane  in  its 
entire  thickness  is  swollen.  There  is  considerable  in- 
duration, and  the  corjDus  spongiosum  may  feel  quite 
firm  and  cord- like.  The  vessels  are  set  as  it  were  in 
a  bed  of  plastic  matter,  which  prevents  them  from 
expanding  equally  with  those  of  the  corpora  caver- 
nosa; hence  the  chordee.  In  very  acute  cases  the 
tension  on  the  capillaries  is  so  great  that  occasion- 
ally  some  of  them  burst,  and  blood  escapes  from  the 
urethra. 

As  the  inflammation  subsides,  the  discharge  gets 
more  watery.     With  proper  treatment  it  disappears 


Chap.  LXIV.]         GONORRH(EAL    CvSTITIS.  343 

altogether,  for  the  natural  termination  is  in  cure. 
Not  one  case  in  a  hundred  ends  in  chronic  thickening 
and  stricture.  Nevertheless,  the  part  remains  a  locus 
resistentise  minoris,  and  subsequent  attacks  are  very 
easily  excited,  though  not  usually  v^ith  the  virulence 
of  the  primary  one. 

CoMsequeiices  of  g'onorrliflea. —  These  are 
local  and  general,  immediate  and  remote.  The  imme- 
diate local  consequences  include  cystitis,  orchitis,  and 
retention  of  urine.  The  remote  local  consequences 
are  stricture  and  its  results,  cystitis,  orchitis,  sur- 
gical kidney,  hypertrophy  of  the  bladder  and  ureters, 
extravasation  of  urine,  urinary  abscess,  etc.  The 
term  "  local "  is  here  used  to  imply  the  structures 
in  anatomical  relationship  with  the  urethra.  The 
general  consequences  are  dependent  on  absorption  of 
some  irritating  matter  from  the  seat  of  primary  in- 
flammation. In  very  rare  cases  acute  fatal  pysemia 
is  induced ;  more  often  the  symptoms  are  less  severe, 
and  then  the  constitutional  state  is  designated 
"  gonorrhoeal  rheumatism,"  on  account  of  the  preva- 
lence wdth  which  articulations  and  fibrous  investments 
are  involved,  rather  than  on  any  known  character  of 
the  virus  showing  its  analogy  with  the  materies  morbi 
of  idiopathic  rheumatism.  Gonorrhoeal  ophthalmia 
occurs  as  a  generalised  affectionj  and  as  an  accident 
from  direct  inoculation. 

Ooitorrhceal  cystitis. — Gonorrhoea  is  the  most 
common  cause  of  cystitis.  It  is  due  to  spreading  of 
the  inflammation  in  the  continuity  of  the  mucous 
membrane,  and  not  to  regurgitation  of  pus.  Il;  is 
possible  that  catheterism  may  be  exceptionally  the 
means  of  conveying  the  discharge.  The  cystitis  is 
most  marked  about  the  neck  of  the  bladder.  Ifc  is 
recognised  symptomatically  by  pain  and  frequency  of 
micturition ;  and  anatomically  by  swelling  and  muco- 
purulent catarrh  of  the   mucous  membrane.     When 


344  Surgical  Pathology.        [Chap.  lxiv. 

gonorrlioea  ends  in  pyaemia,  it  is  generally  by  destruc- 
tive cystitis,  for  in  these  cases  the  mucous  and  sub- 
mucous tissues  are  infiltrated  with  pus,  and  the  mem- 
brane may  be  hsemorrhagic  and  sloughy.  On  the 
supposition  that  gonorrhoea  is  not  a  specific  disease, 
we  must  say  that  pyaemia  is  not  due  solely  to  the 
virulence  of  the  products  of  the  primary  non-infective 
inflammation,  but  to  a  true  infective  process  grafted 
on  to  the  original  simple  urethritis. 

Oonorrlioeal  orcbitis.     (T'ic^e  Acute  orchitis.) 

Retentioii  of  lurine. — This  is  partly  the  result 
of  the  static  obstruction  offered  by  the  swollen  mucous 
membrane,  and  partly  of  the  dynamic  resistance 
due  to  spastic  contraction  of  the  sphincter  vesicae. 
Reflex  paralysis  of  the  expelling  muscles  of  the  bladder 
will  not  account  for  it,  since  the  most  powerful  volun- 
tary contractions  of  the  abdominal  muscles  are  unable 
to  overcome  the  difficulty.  The  intolerable  suffering 
of  the  patient  contrasts  with  his  passive  endurance 
of  retention  from  enlarged  prostate  and  long-standing 
stricture.  This  is  explained  by  the  excessively  sensi- 
tive condition  of  the  inflamed  structures,  and  by  the 
fact  that  the  bladder  is  not  accustomed  to  acute  dis- 
tension of  its  walls  ;  another  exemplification  of  the 
law,  that  morbid  states  suddenly  induced  show  them- 
selves much  more  by  signs  and  symptoms  than  those 
of  slow  development. 

OoitorrEioeal  stricture  of  tlie  urethra  will 
be  treated  of  in  the  general  description  of  organic 
stricture,  since  the  pathological  changes  do  not 
materially  differ  from  those  concerned  in  the  pro- 
duction of  other  forms  of  fibrous  contraction,  and  the 
remote  results  are  the  same. 

Ooiiorrlioeal  affections  of  the  eye. — These 
are:  (1)  Gonorrhoeal  rheumatic  sclerotitis;  (2)  double 
catarrhal  conjunctivitis ;  (3)  purulent  ophthalmia 
(generally  unilateral)  due  to  inoculation. 


Chap.  LXIV.]      GONORRHCEAL    EyE   AfFECTIONS.  345 

(1)  Sclerotitis. — Although  the  symptoms  are  mainly- 
referred  to  the  sclerotic,  it  must  not  be  supposed  that 
the  contiguous  structures  are  not  affected ;  no  more 
than  that  periostitis  exists  without  a  certain  amount 
of  ostitis.  The  physical  signs  are  increased  tension 
of  the  globe ;  injection  of  the  sclerotic  vessels  some- 
times localised  or  intensified  at  the  place  of  attachment 
of  the  external  muscles ;  and  congestion  of  the  ocular 
conjunctiva,  etc.  In  persons  predisposed  to  rheu- 
matism, and  especially  those  of  mature  or  advanced 
age,  the  morbid  changes  and  symptoms  are  those  of 
ordinary  rheumatic  ophthalmitis.  In  fact,  the  diagnosis 
turns  chiefly  on  a  knowledge  of  the  cause. 

Go7iorrh(£al  conjunctivitis  seems  to  be  due  to  ab- 
sorption of  some  irritating  substance  from  the  ure- 
thra, and  its  diffusion  in  the  general  circulation ;  for 
not  only  are  both  eyes  affected,  but  the  symptoms 
are  liable  to  recur  with  recurrence  of  the  urethritis. 
It  can  scarcely  be  a  reflex  nervous  disorder,  for  there 
is  neither  physiological  nor  anatomical  connection 
between  the  structures  primarily  and  secondarily 
involved.  The  inflammation  is  shown  by  hypersemia, 
and  mucous  or  muco-purul-ent  discharge. 

Purulent  ophthalmia  is  mostly,  if  not  always, 
caused  by  direct  inoculation.  It  is  one  of  the  most 
destructive  diseases  of  the  eye.  In  many  cases  the 
sight  is  lost,  and  in  most  it  is  permanently  damaged. 
As  a  rule  only  one  eye  is  affected.  The  palpebral 
conjunctiva  is  greatly  swollen,  and  the  ocular  overlaps 
the  edge  of  the  cornea  (chemosis).  The  cornea 
inflames  and  then  ulcerates,  the  ulceration  usually 
taking  place  at  the  periphery,  for  the  pressure  is 
greater  there  than  at  the  centre  on  account  of  the 
chemosed  conjunctiva.  Sometimes  it  sloughs,  owing 
to  the  stoppage  of  the  circulation  in  the  plasmatic 
canals.  The  interlaminar  spaces  are  crowded  with 
pus  cells  (onyx).     In  the  worst  cases  the  eye-ball  is 


346  Surgical  Pathology.  [Chap. lxv. 

destroyed  by  suppuration  and  sloughing,  only  a 
shrunken  caruncular  mass  remaining ;  short  of  this 
the  cornea  remains  opaque,  and  perhaps  bulged 
(anterior  staphyloma),  or  it  is  collapsed  owing  to 
escape  of  the  vitreous  humour. 


CHAPTER  LXY. 

STRICTURE    OF    THE    URETHRA. 

Three  kmds  are  generally  described  :  (1)  Organic; 
(2)  congestive  ;  (3)  spasmodic. 

Spasmodic  strictiu'e. — Authors  differ  as  to 
the  frequency  and  degree  of  functional,  dynamic,  or 
spasmodic  stricture.  There  seems  no  reason  to  doubt 
its  actual  occurrence,  for  there  is  the  anatomical  basis 
in  the  extrinsic  and  intrinsic  muscles  of  the  urethra ; 
and,  moreover,  a  catheter  may  be  grasped  and  tightly 
held  during  its  passage  at  one  time,  whilst  it  slips 
into  the  bladder  with  great  readiness  at  another.  It 
may  constitute  a  disease  ijer  se,  or,  rather,  it  may  be 
the  only  symptom  of  undue  nervous  or  muscular 
excitability ;  or  it  may  complicate  congestive  and 
oro-anic  strictures. 

Congestive  stricture  is  seen  to  perfection  in 
retention  from  acute  gonorrhoea.  It  adds  to  the 
difficulty  of  micturition  caused  by  organic  stricture 
and  enlarged  prostate,  and  so  explains  those  cases 
where  urine  can  be  voided  one  day  whilst  it  is  re- 
tained the  next.  The  irritation  that  causes  it  may 
be  mechanical,  chemical,  or  functional,  and  it  may 
act  directly  upon  the  part,  or  at  a  distance.  The 
passage  of  a  catheter  constitutes  a  mechanical  irri- 
tant ;    excessive  use  of  alcohol,   and  other  local  and 


Chap.  Lxv.]  Organic  Stricture.  ^4^ 

general  stimulants,  a  physico-clieniical  irritant ;  and 
forced  retention  of  urine,  or  sexual  excitement,  a 
functional  irritant.  Exposure  to  wet  and  cold  evi- 
dently acts  in  a  reflex  manner. 

Tlie  modus  operandi  probably  varies  in  different 
cases.  The  possible  explanations  are  :  (1)  Paralysis 
of  the  muscular  fibre  cells  or  terminals  of  the  nerves 
from  immediate  injury;  (2)  reflex  vaso-constrictor 
paralysis ;  (3)  reflex  vaso-dilator  stimulation. 

Passive  congestion  of  long-standing  is  at  once  the 
cause  and  consequence  of  organic  stricture,  for  the 
irritation  maintained  by  the  stricture  keeps  the  blood- 
vessels dilated ;  and  this  is  accompanied  by  more  or 
less  exudation,  induration,  and  contraction,  like  nut- 
meg cirrhosis  of  the  liver  from  passive  hypersemia 
of  the  hepatic  veins.  After  a  time  the  vessels  lose 
their  tone,  and  are  unable  to  contract,  and  this  may 
remain  long  after  the  primary  source  of  irritation  has 
been  removed. 

Org-aiiic  stricture. —  Gonorrhoeal  urethritis  is 
by  far  the  most  common  cause  of  organic  stricture  ; 
but  traumatism  is  not  rare.  The  urethra  may  be 
injured  from  v^ithout  by  blows  upon  the  perineum, 
or  from  within  by  forcible  instrumentation,  or  impac- 
tion of  a  calculus. 

In  any  case  the  natural  elastic  tissues  of  the 
urethra  are  substituted  by  inflammatory  exudation 
that  undergoes  cicatricial  contraction.  In  the  majority 
of  instances  the  entire  circle  of  the  urethra  is  involved, 
and  the  stricture  is  consequently  annular.  This  is 
the  necessary  result  of  complete  rupture.  Localised 
ulceration  from  the  pressure  of  an  impacted  calculus, 
although  it  leads  to  a  certain  amount  of  contraction, 
may  cause  but  little  difficulty,  as  a  considerable 
portion  of  the  circumference  of  the  walls  remains 
intact. 

The  canal  of  the  urethra  is  only  a  potential  one 


34^  Surgical  Pa  thology.  [Chap.  lxv. 

for  when  the  parts  are  at  rest,  the  opposite  surfaces 
are  in  contact.  The  expansion  of  the  walls  under  the 
pressure  of  the  column  of  urine  during  micturition  is 
more  than  counterbalanced  by  the  contraction  of  the 
newly-formed  connective  tissue  ;  and  so  great  is  the 
resistance  offered  by  the  stricture,  that  the  powerful 
exertion  of  a  hypertrophied  bladder  is  unable  to  cope 
with  it  beyond  the  extent  of  keeping  the  passage 
permeable. 

Post  mortem  a  stricture  does  not  appear  so  tight 
as  during  life,  for  all  vital  contractility  is  abolished, 
and  softening  of  the  fibrous  elements  sets  in  soon 
after  death. 

The  so-called  "  resiliency "  of  a  structure,  which 
accounts  for  recontraction  within  a  short  period  of 
mechanical  dilatation,  is  probably  due  to  combined 
elasticity  and  contractility.  Whilst  there  are  few 
or  no  muscular  fibres  in  tte  stricture  itself,  there  is 
reason  to  believe  that  the  difficulty  experienced  in 
catheterism  is  partly  owing  to  the  spastic  contraction 
of  the  muscles  outside.  This  view  is  supported  by  the 
fact  that  although  a  catheter  may  be  tightly  gripped 
soon  after  engaging  an  orga,nic  stricture,  if  the  parts 
be  allowed  a  short  period  of  rest,  the  instrument  after- 
wards travels  with  comparative  ease.  Of  course  the 
blood-vessels  are  relieved  at  the  same  time,  but  their 
previous  fulness  does  not  seem  sufficient  to  explain 
the  difference  in  the  degree  of  resistance. 

A  toi'idle  stricture  is  one  where  fibrous  bands 
stretch  from  one  part  of  the  urethral  wall  to  another. 
It  is  possible  that  in  some  cases  these  trabeculse  are 
formed  by  the  making  of  false  passages  through  the 
base  of  the  stricture ;  but  as  a  rule  they  are  of 
natural  construction.  Absorption  of  the  central  or 
external  portions  (short  of  the  entire  length)  of  mem- 
branous projections  into  the  canal  of  the  urethra 
would  leave  the  free  edges  as  the  cords  in  question  ; 


Chap.  Lxv.]  Organic  Stricture.  349 

the  same  as  occurs  physiologically  in  the  development 
of  the  chorclse  tenuinese  of  the  heart. 

The  effects  of  treatment.— An  organic  stric- 
ture is  never  cured,  for  whatever  treatment  is  adopted 
the  patient  cannot  dispense  with  the  occasional  use  of 
a  catheter  or  bougie. 

The  different  methods  employed  aim  at  one  or 
more  of  three  attainments :  (1)  Stretching  of  the 
cicatricial  tissue ;  (2)  absorption  of  inflammatory 
products  ;  (3)  the  interposition  of  new  plastic  matter 
(splicing).  In  the  process  of  stretching  by  "gradual 
dilatation  "  the  tissue  elements  are  elongated,  and  in 
all  probability  dislocated  from  one  another  at  the 
same  time.  In  "  forcible  dilatation  "  this  is  undoub- 
tedly the  case ;  in  fact,  the  mechanism  may  be 
described  as  multiple  interstitial  laceration,  for  it  is 
doubtful  if  the  stricture  ever  gives  way  in  one  place 
alone.  Absorption  of  inflammatory  products,  which 
exist  in  the  form  of  recent  exudation,  and  partially 
or  perfectly  organised  fibrous  tissue,  is  effected  by 
the  pressure  of  a  catheter,  especially  when  this  is 
allowed  to  remain  in  the  stricture  for  some  time. 
The  blood-vessels  are  mechanically  supported,  endos- 
mosis  is  favoured,  and  the  result  is  atrophy  from 
continuous  pressure.  The  process  is  analogous  to  the 
dispersion  of  chronic  inflammatory  thickening  of  a 
limb  by  strapping  and  bandaging.  In  internal  ure- 
throtomy the  stricture  is  divided,  and  the  edges 
gape;  the  latter  condition  I  verified  by  post-mortem 
examination  in  a  case  fatal  soon  after  operation. 
Lymph  is  effused  about  the  wound,  and  the  interval  is 
filled  up  by  plastic  matter;  the  same  in  kind,  but 
less  in  degree,  as  when  a  tendon  is  elongated  after 
tenotomy.  Catheterism,  subsequent  to  section,  stretches 
the  young  connective  tissue,  and  with  it,  though  to  a 
slighter  extent,  the  material  of  which  the  stricture 
was  originally  composed. 


3^o  Surgical,  Pathology.         [Chap.  lxvi. 

When  there  is  much  induration  outside  the 
urethra,  internal  urethrotomy  may  fail  to  divide  the 
entire  thickness  of  the  stricture.  It  is  in  these  cases 
that  external  urethrotomy  is  of  such  signal  service. 


CHAPTER  LXYL 

URINARY   ABSCESS.       EXTRA VASATIOX    OF    URINE. 
URINARY   FISTULA. 

Urinary  abscess  is  usually  preceded  by  stric- 
ture, which  is  in  fact  its  principal  cause.  The  tension 
upon  the  urethra  at  and  behind  the  stricture  sets  up 
inflammation,  and  this  leads  to  ulceration  through  the 
walls,  and  consequent  escape  of  a  small  quantity  of 
urine  under  high  pressure  ;  or  the  inflammation  spreads 
to  the  cellular  tissue  outside  the  urethra,  and  there  ends 
in  suppuration.  In  the  latter  case  a  communication 
between  the  urethra  and  the  abscess  cavity  is  subse- 
quently established.  It  is  not  always  easy  to  tell  the 
order  of  sequence,  but  from  the  fact  that  the  cavities 
of  some  perineal  abscesses  due  to  stricture  are  en- 
tirely free  from  the  channel  of  the  urethra,  and  that 
occasionally  urine  first  makes  its  appearance  at  the 
wound  some  time  after  the  abscess  has  burst,  or  has 
been  opened,  it  seems  clear  that  the  second  mode  of 
formation  is  by  no  means  infrequent.  Whatever 
may  be  the  exact  mode  of  formation,  a  barrier  of 
tymph  is  thrown  out  around  the  abscess,  and  this 
checks  the  sudden  outrush  of  urine  and  extravasa- 
tion into  the  spaces  of  the  areolar  meshwork.  The 
pressure  of  the  inflammatory  exudation  outside  the 
urethra  adds  to  the  difficulty  of  the  urine  escaping  by 
the  natural  passage,  and  to  the  chances  of  its  finding 


Chap.  LXVL]  UrINARY  AbSCESS.  35 1 

its  way  into  the  abscess.  In  this  way  the  tension 
becomes  so  great  that  unless  it  is  relieved  by  free 
incision  there  is  great  danger  of  the  wall  of  the  abscess 
breaking  down,  with  consequent  extravasation. 

The  obstruction  to  the  flow  of  urine  may  be 
lessened  by  ulceration  and  sloughing  of  the  strictured 
part  of  the  urethra.  In  very  rare  cases  the  relief 
thus  aflbrded  is  sufficient  to  provide  for  discharge  of 
the  contents  of  the  abscess  per  urethram.  As  a  rule, 
however,  an  artificial  opening  is  made  in  the  perineum, 
and  through  this  the  pent-up  matter  escapes.  Sub- 
sequently the  cavity  of  the  abscess  shrinks,  but  its 
complete  closure  is  often  prevented  by  the  pressure 
of  the  urine  behind  the  stricture,  and  fistula  is  the 
result. 

The  contents  of  the  abscess  consist  of  pus,  urine, 
and  the  debris  of  tissue.  They  are  very  offensive  from 
putrefactive  decomposition. 

The  pressure  of  an  impacted  calculus  may  cause 
an  opening  in  the  urethral  wall  by  ulceration,  and  in 
this  way  the  calculus  may  escape  into  the  sub-urethral 
tissues,  and  there  set  up  suppuration.  The  pus  from 
such  an  abscess  may  make  its  exit  entirely  by  the 
urethra,  since  with  the  disappearance  of  the  calculus 
from  the  natural  passage  the  chief  source  of  obstruc- 
tion to  the  flow  of  urine  is  removed.  Such  cases 
prove  that  high  tension  is  a  far  more  potent  cause  of 
urinary  abscess  and  extravasation  than  the  chemical 
irritation  of  the  tissues  by  urine.  So  long  as  the 
calculus  remains  in  its  new  position  it  is  subject  to 
increase  in  size,  from  the  deposit  of  urinary  salts  as 
the  fluid  bathes  its  surface,  for  it  is  very  seldom  that 
the  orifice,  by  which  the  cavity  lodging  the  stone  com- 
municates with  the  urethra,  closes.  The  incrustation 
of  the  calculus  may  lead  to  difficulty  in  micturition 
later  on,  in  consequence  of  encroachment  upon  the 
urethral  channel. 


352  Surgical  Pathology.         [Chap. lxvi. 

Urinary  abscess  in  connection  with  the  penile 
portion  of  the  urethra  is  usually  the  result  of  impacted 
calculus. 

Extravasation  of  urine. — Either  the  bladder  or 
the  urethra  may  give  way.  When  the  former  ruptures 
through  its  serous  covering  acute  peritonitis  is  set  up. 
When  the  rent  occurs  below  the  attachment  of  the 
false  ligaments  pelvic  cellulitis  is  the  consequence. 
The  causes  of  urethral  extravasation  are  stricture, 
blows  in  the  perineum,  fracture  of  the  pubic  bone, 
and  impacted  calculus.  In  children  the  last-mentioned 
cause  is  the  most  common. 

"  Extravasation  "  differs  from  "  urinary  abscess  " 
in  that  the  urine  is  rapidly  diffused  through  the 
interstices  of  the  cellular  tissue,  instead  of  being 
limited  to  a  comparatively  small  space.  This  depends 
(1)  upon  the  size  of  the  opening  in  the  urethra,  (2) 
upon  the  degree  of  obstruction  in  its  lumen.  The 
loose  areolar  tissue  in  the  perineum  and  scrotum 
offers  but  little  resistance  to  the  escape  of  urine,  as 
the  latter  is  forced  along  under  high  pressure.  The 
irritative  nature  of  the  fluid  and  the  great  tension 
upon  the  blood-vessels  soon  lead  to  stasis  and  wide- 
spread thrombosis  and  gangrene.  The  parts  become 
enormously  swollen.  At  first  they  are  tense  and 
red,  then  they  become  boggy  and  discoloured ;  for 
with  the  cessation  of  the  circulation  exudation  is 
checked  j  and  the  haemoglobin  of  the  blood  is  decom- 
posed. The  derivative  pigments  variously  tinted 
cause  the  skin  to  assume  a  mottled  and  variegated 
aspect — red,  green,  black,  etc.  Subcutaneous,  emphy- 
sematous crackling  can  be  felt.  This  is  due  to  the 
evolution  of  gases  of  putrefaction.  On  cutting  into  the 
gangrenous  tissues  a  sero-sanguinolent  fluid  escapes. 
If  suppuration  have  preceded  the  general  extravasa- 
tion, the  discharge  will  contain  much  pus.  The  local 
treatment   is   directed   to   two  ends :    (1)    Relief   of 


Chap.  Lxvi.]  Urinary  Fistula,  353 

inflammatory  tension,  and  escape  of  decomposing 
fluids  ;  (2)  establishment  and  maintenance  of  a  free 
passage  from  the  bladder;  or,  in  other  words,  the 
removal  of  the  efi'ects  of  past  extravasation,  and  the 
prevention  of  further  mischief.  So  long  as  the 
lymphatics  and  blood-vessels  remain  exposed  to 
putrescent  matter  the  danger  of  septic  absorption 
continues.  Asthenia  and  septicaemia  are  the  conse- 
quences to  be  feared  and  guarded  against. 

The  path  of  the  extravasation  is  directed  by  the 
attachments  of  the  deep  membranous  layer  of  the 
superficial  fascia  ;  hence  it  passes  from  the  perineum 
to  the  scrotum,  and  so  on  to  the  abdomen.  Limited 
yet  fatal  extravasation  has  been  known  to  follow 
tapping  of  the  bladder  through  the  rectum  and  above 
the  pubes, 

UriMary  fistula. — The  bladder  may  communi- 
cate with  the  rectum  or  vagina,  and  the  urethra  with 
the  external  surface,  rectum,  or  vagina.  Recto- 
vesical fistula  is  generally  the  consequence  of  some 
operative  measure,  such  as  rectal  lithotomy,  or  tap- 
ping of  the  bladder  per  rectum ;  but  it  also  arises 
during  the  progress  of  a  pelvic  abscess.  In  the  latter 
case  a  direct  passage  is  set  uf)  between  the  two 
viscera  by  ulceration  or  sloughing  of  their  contiguous 
walls  ;  or  a  sinuous  tract  intervenes.  Vesico-vaginal 
fistula  results  from  long-continued  pressure  of  the  foetal 
liead  during  parturition,  and  from  vaginal  lithotomy. 
Ordinary  perineal  urinary  fistula  is  a  common  sequel 
of  urinary  abscess  and  extravasation.  These  unna- 
tural passages  remain  open  from  one  or  both  of  two 
causes  :  obstruction  to  the  flow  of  urine  per  via'ni 
natitralem  ;  and  want  of  rest,  which  entails  the  absence 
of  those  conditions  necessary  to  the  union  of  two 
opposed  granulating  surfaces.  No  amount  of  treat- 
ment is  likely  to  be  successful  in  a  case  of  perineal 
fistula    whilst    a    stricture    of    the    urethra     remains 


354  Surgical  Pathology.       [Chap.  lxvii. 

undilated,  for  there  is  a  frequently  recurring  dis- 
tention of  the  walls  of  the  fistula  by  the  stream  of 
urine  diverted  from  its  proper  course.  The  physio- 
logical contraction  of  the  muscles  of  the  bladder, 
vagina,  and  rectum  causes  one  granulating  surface  to 
glide  upon  the  other,  and  so  keeps  up  continual 
irritation  and  exudation  from  the  vessels.  An  impor- 
tant point  in  the  management  of  these  cases  after 
operation  is,  as  far  as  possible,  to  relieve  the  viscera 
involved  of  their  functional  activity. 

Where  fistulous  tracts  are  long  and  sinuous,  it  is 
often  necessary  to  lay  them  freely  open,  otherwise  the 
external  openings  may  contract,  or  even  close,  before 
the  granulations  in  the  deeper  recesses  cease  to  secrete 
more  than  suffices  for  their  agglutination.  By  this 
unequal  contraction,  cul-de-sacs,  or  segments  of  the 
main  sinus,  become  filled  with  pus,  which  goes  on 
accumulating  until  the  tension  is  high  enough  to 
burst  open  the  original  orifice,  or  a  gradual  process  of 
ulceration  establishes  a  new  one. 


CHAPTER   LXYII. 

HYPERTROPHY    OF    THE    BLADDER. 

Hypertrophy  of  the  muscular  coat  of  the  bladder 
is  the  result  of  increased  functional  activity.  As  a 
rare  event,  this  happens  in  children  from  excess  of 
intrinsic  nervous  or  muscular  irritability  of  the  organ. 
With  this  exception,  hypertrophy  may  be  considered 
as  consequent  on  obstruction  to  the  flow  of  urine  in 
some  part  of  the  urethra.  Enlargement  of  the  pro- 
state and  organic  stricture  are  by  far  the  most  com- 
mon antecedents.     In  these  cases  the  hypertrophy  is 


Chap.  Lxvii.]  Hypertrophy  of  the  Bladder.    355 

purposive  or  compensatory.      It  is  called  into  existence 
by  the  stimulus  of  increased  resistance  (Fig.  2). 

Up  to  a  certain  extent,  hypertrophy  is  able  to 
keep  pace  with  the  obstruction ;  but,  as  a  rule,  sooner 
or  later  the  pressure  becomes  so  great  that  dilatation 
is  superadded,  the  same  as  in  "  dilated  hypertrophy  " 
of  the  heart.  The  walls  of  the  bladder  may  be  so 
expanded  that  the  hypertrophy  is  masked.  The  true 
index  of  its  existence  is  the  amount  or  bulk  of  the 
entire  muscular  coat,  and  not  simply  its  thickness. 
When  the  distention  is  very  great,  there  is  compara- 
tive powerlessness,  and  the  condition  is  known  as 
atony.  Ceteris  paribus  the  atony  is  proportionate  to 
the  acuteness  of  the  distention.  There  are  several 
factors  concerned  in  its  production  :  (1)  Exhaustion 
of  muscular  irritability  from  repeated  futile  efforts 
to  overcome  the  resistance  ;  (2)  deficiency  of  innerva- 
tion ;  (3)  degeneration  of  the  muscular  fibre  cells. 

As  long  as  the  bladder  is  able  to  empty  itself,  the 
obstruction  may  be  very  great  without  causing  atony  ; 
for,  in  the  intervals  of  physiological  rest,  repair  takes 
place.  Permanent  tension  means  exhaustion.  A 
consideration  of  these  facts  explains  why,  in  most 
cases,  dilatation  succeeds  hypertrophy  from  enlarged 
prostate,  and  why,  as  an  exceptional  circumstance, 
the  hypertrophied  bladder  remains  empty  and  con- 
tracted, and  is  smaller  than  the  prostate. 

The  difficulty  interposed  in  the  way  of  free  circu- 
lation through  the  vessels  of  the  mucous  membrane 
leads  to  atrophy  of  the  more  highly  developed 
elements  and  areolar  hyperplasia  of  the  submucous 
tissue. 

Hypertrophy  and  dilatation  of  the  ure- 
ters.— The  pathology  and  morbid  anatomy  are  the 
same  as  in  the  corresponding  states  of  the  bladder. 


--6 

0D° 


CHAPTER   LXYIII. 

CYSTITIS  :    ULCERATION    OF    THE    BLADDER. 

The  causes  of  cystitis  are  (1)  spreading  of  the 
inflammatory  process  from  one  of  the  neighbouring 
passages,  as  in  gonorrhoea!  urethritis ;  (2)  tension  on 
the  walls  of  the  bladder,  as  in  retention  from  stric- 
ture, enlarged  prostate,  and  fracture  of  the  spine  ;  (3) 
irritation  of  the  mucous  membrane  by  the  chemical 
products  of  decomposition  of  urine  ;  (4)  mechanical 
irritation  from  a  calculus,  etc.  ;  (5)  vaso-motor  and 
trophic  changes  consequent  on  injury  or  disease  of  the 
central  nervous  system;  (6)  new  growths,  e.g.,  cancer, 
and  tubercle. 

It  frequently  happens  that  more  than  one  cause  is 
concerned  in  producing  cystitis  ;  e.g.,  in  fracture  of 
the  spine  there  is  tension  from  the  retention  of  urine ; 
perverted  nutrition  of  the  mucous  membrane  from 
disordered  innervation  ;  acute  congestion  from  para- 
lysis of  the  vaso-motor  nerves  ;  and  sometimes,  though 
unwarrantably,  septic  decomposition  of  urine  from 
the  passage  of  an  unclean  catheter. 

Decomposition  of  urine  is  both  a  cause  and  con- 
sequence of  cystitis. 

In  the  viscid  mucus  of  chronic  catarrh  there 
exists  a  ferment  capable  of  setting  up  the  alkaline 
fermentation.  In  consequence  of  this,  urea  is  con- 
verted into  carbonate  of  ammonia.  But  this  is  not 
the  only  product  of  the  decomposition,  and,  probably, 
not  the  chief  one,  in  so  far  as  the  cause  or  increase  of 
the  inflammation  is  concerned. 

^        Varieties  of  cystitis. — These  may  be  arranged 
on  two  bases:  (1)  As  to  the  intensity  of  the  inflam- 


Chap,  i^xviii.]  Acute  Cystitis.  357 

mation,  acute  and  chronic ;  (2)  as  to  the  cause,  e.g., 
calculous  cystitis,  tubercular  cystitis,  etc. 

The  term  '  catarrh  "  is  somewhat  misleading ;  for 
clinically  it  refers  to  chronic  and  subacute  inflamma- 
tion, whilst  pathologically  it  receives  its  interpretation 
more  or  less  in  every  case  of  cystitis. 

Acute  cystitis  consists  of  increased  multiplica- 
tion, mucoid  transformation,  and  shedding  of  the 
epithelial  cells,  and  of  exudation  of  liquor  sanguinis 
and  migration  of  leucocytes.  The  iwoducU  vary  in 
appearance  and  consistence  according  to  the  degTee  of 
inflammation.  At  first  th-ey  are  comparatively  thin, 
the  serum  of  the  blood  mingling  with  and  diluting 
the  mucus  derived  from  dissolution  of  the  distended 
epithelial  cells.  A  number  of  corpuscles  are  held  in 
suspension,  but  not.  as  yet  in  sufficient  numbers  to 
cause  more  than  a  cloudiness  of  the  fluid.  As  the 
inflammation  heightens,  the  discharge  becomes  muco- 
purulent and  then  purulent ;  but  in  every  stage  it 
contains  a  considerable  quantity  of  mucin.  Then,  as 
resolution  takes  place,  it  diminishes  in  quantity,  and 
gets  more  glutinous,  and  finally  the  secretion  returns 
to  the  normal. 

In  comparatively  rare  cases  the  exudation  is 
highly  fibrinous,  coagulating  upon  the  surface  of  the 
mucous  membrane,  and  forming  a  cast  of  the  interior 
of  the  bladder.  Anatomically,  it  resembles  the  false 
membrane  of  croup  and  the  casts  of  plastic  bronchitis. 

"When  the  inflammatory  congestion  is  very  intense, 
capillary  haemorrhages  occur  both  in  the  interstices  of 
the  membrane  and  on  its  surface ;  the  exudation  is 
consequently  more  or  less  sanguinolent. 

Stasis  and  thrombosis  may  be  so  extensive  as  to 
entail  death  of  portions  of  the  mucous  membrane. 
Flakes  or  shreds  of  slough  are  set  free  by  liquefaction 
of  their  attachments,  and  floated  ofi"  by  the  stream  of 
exudation  and  the  urine  with  which  they  are  bathed. 


358  Surgical  Pathology,      [cimp.  lxviii. 

It  must  be  remembered  that  the  fluid  passed  per 
urethram  varies  not  only  as  the  characters  of  the  inflam- 
matory products,  but  as  the  amount  of  urinary  admix- 
ture and  the  existence  and  degree  of  decomposition. 

Chronic  and  subacute  cystitis  is  exceedingly 
common  as  the  result  of  hypertrophied  prostate,  and 
stricture  of  the  urethra.  In  both  these  diseases 
there  is  difficulty  in  completely  emptying  the  bladder. 
Very  often  it  amounts  to  impossibility,  so  that  after 
each  effort  at  micturition  there  is  a  residuum  of 
urine.  This  is  very  liable  to  decompose,  and  increase 
and  perpetuate  the  cystitis. 

When  the  urine  is  allowed  to  stand,  it  will  be 
found  that  thick  ropy  mucus  clings  so  tenaciously  to 
the  bottom  of  the  vessel  that  inversion  of  the  latter 
does  not  suffice  to  disengage  it.  It  is  frequently  alka- 
line in  reaction  when  passed ;  if  not,  it  A-^ery  quickly 
becomes  so.  It  has  an  offensive  ammoniacal  smell. 
Besides  mucus,  it  contains  pus  and  dirty  grumous 
matter,  consisting  of  epithelial  cells,  blood  corpuscles, 
and  amorphous  debris.  It  deposits  crystals  of  triple 
phosphate. 

The  mucous  membrane  is  deeply  congested,  much 
swollen,  and  sometimes  pigmented  to  a  marked  degree. 
The  summits  of  the  temporary  rugae,  and  even 
broader  tracts,  are  often  encrusted  with  sabulous 
material  (inspissated  mucus  and  pus  impregnated  with 
earthy  salts).  The  greater  part  of  the  surface  may 
appear  of  a  dirty  grey  colour. 

The  ureters  and  kidneys  are  generally  diseased. 
{Vide  Surgical  kidney.) 

Cystitis  varies  from  acute  purulent  infiltration 
and  discharge  to  chronic  mucous  catarrh.  The  terms 
'^  acute,"  "subacute,"  and  "chronic"  do  not  denote 
fixed  pathological  landmarks.  They  are  used  to  indi- 
cate groups  of  symptoms  and  morbid  appearances  of 
comparative  but  indeterminate  intensity. 


Chap,  Lxviii.]  Ulceration  of  the  Bladder.        359 

Ulceration  of  the  bladder  is  caused  by  (1)  the 
mechanical  irritation  of  a  stone,  etc.  \  (2)  the  breaking 
down  of  tubercular  deposits;  (3)  malignant  disease; 
(4)    destructive     inflammation     arising    from     other 


Fig.  55. — Tubercular  Ulceration  of  the  Bladder. 

a,  Miliary  granulations  ;  &,  excavated  ulcers  ;  c,  vesicula  seminalis;  d,  vas 
deferens,  enlarged  from  tubercular  inflammation.  (Reduced  one  half.) 

sources ;  e.g.,   gonorrhoea,   septic  infection  of  a  litho- 
tomy wound,  etc. 

Ulceration  from  the  pressure  and  friction  of  a 
stone  is  generally  situated  about  the  neck  of  the 
bladder,  since  this  is  the  part  most  subject  to  injury 
when  the  viscus  empties  itself  of  its  urinary  contents. 


360  Surgical  Pathology.        [Chap.  lxix. 

The  ulcer  is  comparatively  superficial,  and  without 
marked  induration  of  the  base.  It  is  usually  asso- 
ciated with  advanced  cystitis  of  the  entire  mucous 
membrane. 

Tubercular  ulceration  is  due  to  the  softening  of 
miliary  tubercles  and  consecutive  destruction  of  the 
surrounding  tissues.  The  ulcers  are  multiple,  as  a  rule 
(Fig.  55).  Though  most  common  at  the  base,  they  are 
often  indefinitely  distributed.  Their  margins  are 
sharply  defined,  and  frequently  undermined.  By  the 
coalescence  of  contiguous  ulcers  the  mucous  and  sub- 
mucous tissues  may  be  destroyed  over  a  wide  expanse. 
Tubercular  ulcers  of  the  bladder,  ureters,  and  urethra 
may  be  found  in  the  same  subject,  together  with 
miliary  granulations  in  the  kidneys,  testicles,  and 
other  organs. 

Malignant  tumours  of  the  bladder  ulcerate  early, 
for  in  addition  to  their  intrinsic  tendency  to  dis- 
integration, they  are  subject  to  injury  by  muscular 
contraction. 

When  treating  of  acute  cystitis  it  was  remarked 
that  the  circulation  might  be  so  far  arrested  as  to 
lead  to  ulceration  and  sloughing  of  the  mucous 
membrane.  This  is  all  the  more  likely  to  occur 
where  the  inflammation  is  infective. 


CHAPTER  LXIX. 

TUMOURS    OF    THE   BLADDER. 

Tumours  of  the  bladder,  like  those  of  other  hollow 
viscera,  are  liable  to  assume  the  polypoid  or  villous 
form.  This  is  notably  the  case  with  regard  to  benign 
growths,  but   the   malignant  ones   are   not   exempt. 


Chap.  LXI X . ]      TUMO UR S    OF    THE   BlA DDER .  'Z6l 


The  peculiarity  depends  more  upon  unequal  resistance 
than  on  a  special  predisposition  of  the  new  formation 
to  enlarge  in  a  certain  direction.  On  account  of  the 
varying  amount  of  support,  consequent  on  the  state 
of  tension  of  the  walls  of  the  bladder,  and  the 
disturbance  of  the  circulation  in  the  tumour  caused 
by  contraction  of  the  muscular  coat,  haemorrhage  is 
usually  a  prominent  symptom.  It  is  more  likely  to 
occur,  and  in  profusion,  in  those  cases  where  the 
blood-vessels  are  large,  numerous,  thin-walled,  and 
imbedded  in  soft  loose  tissue;  e.g.,  in  simple  villous 
tumour  and  villous  cancer.  Bleeding  may  be  the 
first,  and  for  a  long  time  the  only,  indication  of  a 
gro"wi:h.  But  the  diagnosis  may  often  be  verified 
by  a  microscopical  examination  of  the  urine,  and 
especially  that  drawn  off  by  a  catheter.  In  one  case 
I  found  numerous  delicate  tufts  of  villous  growth,  and 
in  another  a  minute  fragment  of  columnar  epithelioma. 
This  method  of  investigation  is  of  gTeat  importance 
where  the  existence  of  a  benign  tumour  is  suspected ; 
since  there  is  an  absence  of  induration  of  the  walls  of 
the  bladder. 

Malii^nant  tiimoiirs  of  tlie  bladder  comprise 
villous  cancer  (encephaloid),  epithelioma,  and  sarcoma. 
They  are  mostly  primary,  beginning  in  the  bladder  or 
neighbouring  parts,  vagina,  rectum,  or  prostate. 

Villous  cancer  is  very  rapid  in  its  growth.  The 
surface  of  the  tumour  is  flocculent  from  delicate  out- 
growths and  shreds  of  disintegrating  tissue.  The 
base  is  broad,  and  not  limited  to  the  mucous  mem- 
brane. In  fact,  there  is  infiltration  of  the  walls  of 
the  bladder.  The  trigone  is  the  usual  seat  of  the 
disease.  The  surrounding  structures  may  be  involved. 
Haemorrhage,  and  painful  and  frequent  micturition, 
are  the  chief  symptoms. 

Epithelioma, — Authors  differ  as  to  the  relative 
frequency  of  epithelioma  and  encephaloid  cancer  of 


362  Si'RGiCAL  Pathology.        [Chap.  lxix. 

the  bladder.  There  are  two  facts  that  help  to  explain 
the  discrepancy ;  firstly,  cases  of  sarcoma  have  been 
included  with  soft  cancers ;  and  secondly,  both  the 
tumours  in  question  (epithelioma  and  encephaloid 
cancer)  are  of  epithelial  origin,  and  the  disposition 
and  relative  amount  of  stroma  and  cells  vary.  The 
natural  surface  epithelium  of  the  bladder  is  flattened, 
and  the  cells  of  the  deeper  layers  are  fusiform  or 
columnar.  Each  variety  may  be  represented  in  the 
new  growth.  I  have  met  with  pure  columnar  epithe- 
lioma. The  tumour  is  of  firmer  consistence  than 
encephaloid  cancer,  and  the  surface  is  generally 
smoother,  it  may  be  unevenly  lobulated. 

Sarcoma.  —  The  clinical  and  pathological  cha- 
racters are  those  of  round  and  spindle-celled  sarcoma 
generally. 

Beiii§ii  tumoio'S  of  the  bladder  are  almost 
invariably  polypoid,  or  villous.  They  have  a  special 
tendency  to  grow  from  the  trigone  near  the  orifices  of 
the  ureters.  By  far  the  most  common  variety  is  the 
simple  villous  tumour  (Fig.  74.)  This  may  be  single 
or  multiple.  Occasionally  it  is  diffuse,  the  greater 
part  of  the  mucous  membrane  being  covered  with  a 
shaggy,  flocculent  coa.t.  The  villi  are  arborescent  in 
some  cases,  filiform  in  others.  The  mucous  mem- 
brane appears  healthy  close  up  to  the  insertion  of 
the  outgrowths,  or  only  unusually  rough  from  fine 
villosities.  There  is  no  invasion  of  the  deeper 
structures.  This  is  also  true  of  the  other  benign 
growths.  It  is  an  important  feature,  since  it  serves  to 
distinguish  "villous  tumour  "  from  "villous  cancer" 
eA^en  in  the  early  stages  of  development  of  the  latter, 
when  the  two  formations  have  such  a  close  surface 
resemblance  to  one  another.  The  basis  of  the  villous 
or  papillary  processes  consists  of  a  delicate  stroma  of 
fibrous,  or  mucous  tissue  richly  supplied  with  large 
capillary  vessels.     The  epithelium  may  be  squamous, 


Chap.  Lxix.j    Tumours  of  the  Bladder. 


or  columnar,  and  disposed  in  few  or  many  layers. 
Granules  of  blood  pigment,  scattered,  or  in  groups, 
may  frequently  be  seen  in  the  substance  of  the  growth. 
These  are  the  "^  remnants  of  interstitial  extravasations, 


Fig.  56. — Mucous  Polypi  of  the  Bladder  of  a  Female  Child,  aged 
eighteen  months. 

The  majority  are  attached  around  the  orifice  of  the  right  ureter.  The  urinaiy 
organs  have  heen  removed  in  their  entirety,  together  with  the  rectum  and  a 
portion  of  the  pelvis,  a,  polypi ;  6,  the  same  prolapsed,  and  congested  from 
partial  strangulation  by  the  dilated  urethra;  c,  vagina;  d,  rectum  ;  e,  cut 
surface  of  divided  symphysis  pubis ;  /,  dilated  ureter.    (Reduced  one  half.) 

and  not  the  result  of  true  physiological  pigmentation 
by  the  agency  of  the  protoplasm  of  the  cells. 

Next  in  order  of  frequency  to  villous  tumour  comes 
fibroma,  or  fibrous  'polypus.  It  is  distinctly  pedun- 
culated, and  of  firm  fleshy  consistence. 


364  Surgical  Pathology.  [Chap.  lxx. 

Mucous  or  gelatinous  polypus  is  a  great  rarity. 
Paget  records  two  cases.  Figs.  56  and  64  were  taken 
from  one  that  came  under  my  notice  at  University 
College  Hospital.  With  the  exception  that  the 
epithelium  is  squamous,  these  polypi  differ  in  no 
essential  particular  from  the  common  nasal  variety. 

A  pedunculated  outgrowth  from  the  prostate 
sometimes  projects  into  the  bladder.'  Clinically  it 
may  be  classed  with  the  other  vesical  tumours,  but 
pathologically  it  is  quite  distinct  from  them. 


CHAPTER  LXX. 

HEMATURIA. 

Blood  may  escape  from  any  part  of  the  urinary 
tract,  from  the  Malpighian  glomeruli  of  the  kidney 
down  to  the  spongy  portion  of  the  urethra.  In  the 
diagnosis  of  its  source  one  has  to  pay  attention, 
amongst  other  points,  to  its  quantity,  colour,  degree 
of  admixture  with  the  urine,  and  the  period  at  which 
it  makes  its  appearance  during  micturition. 

When  the  blood  comes  from  the  kidney  it  is 
usually  quite  dark,  from  reduction  of  the  oxy-hsemo- 
globin  by  the  urine ;  but  there  are  exceptions  to 
the  rule.  I  have  known  it  to  be  florid  in  copious 
bleeding  from  a  cancerous  tumour.  Yery  large 
effusions  generally  come  from  the  kidney  or  the 
bladder.  Profuse  hsemorrhage  from  the  urethra  is 
known  by  the  fact  of  its  escaping  independent  of  the 
act  of  micturition. 

Heemorrliage  Irom  the  liidney  may  be  in 
small  or  dangerously  large  quantity.  The  causes  of 
severe  haemorrhage  are  (1)  malignant  tumour;  (2) 
laceration   of  the  kidney ;    (3)    congestion   in   acute 


Chap.  LXX.]  H.-^MATURIA.  365 

Bright's  disease  ;  (4)  reflex  hypersemia,  from  irrita- 
tion of  some  part  of  the  urinary  passages,  e.g.^  by  tbe 
dilatation  of  a  stricture  of  the  urethra ;  (5)  disturb- 
ance of  the  spinal  nervous  system.  {Vide  Trophic 
lesions.)  Renal  calculus,  tubercular  disease  of  the  kid- 
ney, and  other  morbid  states  occasionally  give  rise  to  it. 

The  bleeding  from  primary  cancer  and  sarcoma  of 
the  kidney  may  be  very  profuse,  but  its  occurrence  is 
by  no  means  certain.  One  cause  of  immunity  is 
obstruction  of  the  ureter  by  a  projection  from  the 
growth.  Secondary  cancer  is  less  vascular  than 
primary,  and  it  usually  exists  in  the  form  of  nodules, 
instead  of  a  soft  fungoid  mass,  so  the  chances  of 
haemorrhage  are  more  remote. 

In  laceration  of  the  kidney,  the  hsematuria  is 
likely  to  be  very  great,  unless  the  organ  is  completely 
crushed,  or  the  ureter  ruptured. 

In  acute  Bright's  disease  the  bleeding  is  salutary 
within  a  certain  range.  It  is  nature's  mode  of  giving 
relief  to  the  over-distended  vessels.  The  mechanism 
consists  of  high  blood-pressure  and  diminished  power 
of  resistance  from  degeneration  of  the  walls  of  the 
capillaries. 

The  haemorrhage  from  reflex  hypersemia  can  be 
explained  in  two  ways  :  (1)  a  general  flooding  of  all 
the  vessels  of  the  kidney,  from  vaso-motor  paralysis ; 
(2)  contraction  of  the  renal  arteries,  and,  as  a  con- 
sequence, venous  reflux  into  the  capillaries. 

Hseiiiorrliage  from  the  lu^eters  is  never  very 
great.  The  causes  are  (1)  the  passage  of  a  calculus ; 
(2)  simple  and  tubercular  inflammation. 

Hsemorrliag^e  from  the  bladder,  when  pro- 
fuse, is  strongly  suggestive  of  villous  growth,  or  acute 
ulceration  opening  up  a  comparatively  large  vessel. 
Inter^nittent  JtcBmaturia  depends  on  the  presence  of  an 
animal  parasite,  Bilharzia  haematobia.  It  may  extend 
over  many  years.     Adults  rarely  get  rid  of  the  disease. 


366  Surgical  Pathology.        [Chap.  lxxi. 

Other  causes  of  vesical  hsematuria  are  calculus  and 
cystitis. 

Heeniorrhag^e  from  the  prostate  and 
iiretlira. — Prostatitis,  prostatic  abscess,  malignant 
disease,  and  catheterism  should  be  inquired  after  in 
the  former  case.  Traumatism  from  without  and 
within,  over-distention  of  the  erectile  tissue  of  the 
corpus  spongiosum,  acute  urethritis,  urethral  chancre, 
and  the  passage  of  a  calculus  in  the  latter.  In  old 
men  with  enlarged  prostates,  haemorrhage  from  the 
veins  and  capillaries  is  at  times  sudden  and  copious.  It 
must  be  borne  in  mind  that  "blood  in  the  urine"  is 
not  synonymous  with  "hsematuria."  The  admixture 
may  take  place  after  the  urine  is  voided,  the  blood 
being  derived  from  some  other  source  than  the  uri- 
nary tract. 


CHAPTER  LXXI. 

DISEASES    OP    THE    PROSTATE    GLAND. 

Hypertrophy  of  the  prostate  is  a  disease 
incidental  to  advanced  age.  The  morbid  anatomy  is 
sufficiently  precise,  but  the  etiology  is  unknown.  The 
entire  gland  may  be  the  seat  of  diffuse  hyperplasia,  or 
a  portion  of  it  only  may  be  enlarged,  or  circumscribed 
nodules  may  form  in  its  substance  (the  so-called 
"  prostatic  glandular  tumours  ") ;  or,  lastly,  similar 
masses  may  project  from  its  surface,  as  in  the  analo- 
gous case  of  the  thyroid.  What  were  formerly 
designated  "  fibrous  tumours  "  of  the  prostate  are  now 
known  to  consist  in  the  main  of  unstriped  muscular 
fibre-cells.  Histologically,  nothing  is  observed  that  is 
not  typified  in  the  normal  structure  (Fig.  57). 

The     nearest    approach    is    made     by     "  uterine 


chs.'p.uK.^i.]  Hypertrophy  of  the  Prostate.     367 

fibroids,"  but  the  latter  do  not  contain  glandular 
elements.  Hypertrophy  of  the  prostate  stands,  as  it 
were,  on  the  border-land  of  new  formations  or  growths, 


Fig.  57.— Section  of  a  so-called  Prostatic  Glandular  Tumour 
(Lobulated  Hypertrophy). 

A  nodule  as  large  as  a  walnut  was  shelled  out  during  the  extraction  of  a  vesical 
calculus,  a,  Glandular  recess ;  b,  involuntary  muscular  flbre ;  c,  blood-vessel,  x  265. 

and  chronic  inflammatory  neoplasise ;  but  the  general 
likeness  does  not  imply  intrinsic  pathological  affinity. 
So  long  as  the  prostatic  urethra  is  not  encroached 
upon,  the  gland  may  assume  considerable  proportions 
without  giving  rise  to  symptoms. 


t68  Surgical  Pathology.       [Chap,  lx  xi. 


J 


Cancer  of  tlie  prostate  is  not  common.  The 
encephaloid  variety  is  said  to  be  that  usually  met 
with.  The  few  cases  that  I  have  seen  were  hard 
enough  to  merit  the  name  "  scirrhus."  The  symptoms 
generally  are  those  of  stone  in  the  bladder.  At  first 
the  induration  and  enlargement  simulate  the  signs  of 
chronic  prostatitis  and  prostatic  hypertrophy.  Later 
on,  the  acuteness  of  the  patient's  suffering,  the  wasting 
of  the  body,  the  repeated  haemorrhages,  and,  it  may  be, 
the  implication  of  surrounding  structures,  clear  up  the 
diagnosis. 

Prostatitis  and  prostatic  abscess. — Acute 
prostatitis  is  mostly  a  sequel  of  gonorrhoeal  urethritis, 
but  it  may  be  caused  by  instrumentation,  impaction 
of  a  calculus,  and  other  modes  of  injury.  The  gland 
is  excessively  tender.  It  is  swollen  and  indurated. 
Pus  may  escape  fi'om  the  inflamed  prostatic  urethra 
without  the  occurrence  of  parenchymatous  suppuration. 
Prostatic  abscess  is  recog-nised  by  throbbing  pain, 
and  by  the  detection  of  bogginess  or  fluctuation  per 
rectum,  and  by  the  discharge  of  matter  in  considerable 
quantity.  It  usually  bursts  into  the  urethra,  but  it 
sometimes  opens  into  the  rectum,  or  in  the  perineum. 
Piles  occasionally  develop  meanwhile.  Inflammation 
and  ]3us  formation  may  occur  around  the  gland  (peri- 
prostatitis). 

Chronic  prostatitis  is  the  sequel  of  an  acute  attack, 
or  the  inflammation  is  of  moderate  degree  from  the 
first.  Gleet,  syphilis,  vesical  calculus,  and  catheterism 
are  the  chief  causes.  The  morbid  changes  are  the 
same  in  kind  as  in  the  acute  disease.  The  gland  may 
be  left  permanently  hard  and  enlarged.  On  section 
it  looks  greyish  and  somewhat  translucent,  not  unlike 
a  moderately  firm  scirrhous  tumour.  The  secreting 
glands  and  ducts  are  marked  by  pale  yellow  spots  and 
streaks. 

Tubercle    of  tlie    prostate    is    seldom    seen 


Chap.  Lxxi.]         Prostatic  Calculi.  369 

except  in  conjunction  with  a  similar  affection  of  the 
epididymis,  vasa  deferentia,  and  vesiculse  seminales. 
The  kidney,  ureters,  bladder,  and  urethra  may  be 
involved  at  the  same  time. 

The  tubercles  are  at  first  discrete,  then  they  be- 
come confluent.  Simple  chronic  prostatitis  is  set  up 
around  them.  The  tubercles,  and  the  exudation  pro- 
ducts in  which  they  are  embedded,  caseate,  and  the 
mass  sometimes  breaks  down,  forming  an  abscess  with 
purulent  and  cheesy  contents,  like  as  in  a  strumous 
lymphatic  gland. 

Tubercle  of  the  prostate  is  more  common  than  is 
generally  supposed.  In  all  cases  of  tuberculosis  of 
other  parts  the  prostate  should  be  examined. 

Corpora  amylacea  are  said  to  be  usually 
present  in  the  prostates  of  adults.  They  are  of 
microscopical  dimensions,  or  of  such  a  size  as  to  be 
clearly  visible  to  the  naked  eye.  Individually  they 
may  attain  a  diameter  of  from  y^  to  \  of  an  inch. 
Collectively  they  sometimes  form  masses  of  consider- 
able magnitude,  being  embedded  in  some  cementing 
substance,  and  enclosed  in  a  common  capsule.  They 
are  for  the  most  part  composed  of  concentric  laminae. 
In  their  interior  may  be  seen  granular  particles,  or 
even  nuclei  and  cells.  They  may  be  coloured  brown 
or  black.  The  chief  alteration  to  which  they  are 
subject  is  calcification.  They  have  been  found  in 
phleboliths  in  the  prostatic  veins. 

Prostatic  calculi. — Those  of  intryisic  prostatic 
origin  probably  begin  as  a  deposit  of  organic  matter 
in  the  glandular  acini  or  ducts.  This  would  be 
followed  by  calcareous  infiltration  and  accretion. 

The  constituent  salts  are  phosphate  and  carbonate 
of  lime,  chiefly  the  former. 

These  calculi  may  be  single  or  multiple.  By  their 
pressure  the  tissue  of  the  prostate  is  more  or  less 
absorbed 

Y 


370  Surgical  Pathology.      [Chap.  lxxii. 

They  may  be  encapsuled,  or  lie  loose  in  a  cavity, 
or  project  into  the  prostatic  urethra. 

When  there  are  several  in  the  same  subject  they 
are  liable  to  be.  facetted  by  mutual  attrition ;  and  as 
felt  per  rectum  they  may  give  a  grating  sensation  as 
they  are  made  to  rub  one  against  the  other. 

A  vesical  calculus  may  become  impacted  in  the 
prostatic  urethra,  and  ultimately  embedded  in  the 
substance  of  the  gland. 


CHAPTER  LXXII. 

SURGICAL    KIDNEY. 

Surgical  kidney  consists  essentially  of  an  inter- 
stitial or  intertubular  nephritis.  It  differs  from 
granular  or  gouty  kidney  as  follows  :  (1)  The  inflam- 
matory changes  are  more  irregularly  disposed  ;  (2)  the 
progress  of  the  disease  may  be  very  rapid  ;  if  chronic, 
it  is  subject  to  repeated  exacerbations  \  (3)  it 
frequently  ends  in  suppuration;  (4)  it  is  usually 
accompanied  by  cystitis  and  pyelitis ;  (5)  the  con- 
comitant and  consequent  organic  changes  are  limited 
to  the  urinary  apparatus  ;  there  is  no  hypertrophy  of 
the  heart,  nor  a  general  systemic  arterio-capillary 
fibrosis. 

Causes.  —  These  come  under  two  heads:  (1) 
Those  that  raise  the  tension  in  the  renal  tubes  and 
capillaries ;  (2)  septic  poisoning. 

The  tension  may  be  increased  by  interference  with 
the  escape  of  urine  from  stricture  of  the  urethra; 
enlarged  prostate ;  obstruction  of  one  or  both  ureters, 
from  ia)  impacted  calculus,  (6)  stricture  from  ulceration 
and  compression  by  a  tumour,  or  organised  lymph 
from   pelvic   cellulitis    {vide   Lancet^    1879,    p.    769, 


Chap.  Lxxii.]  Surgical  Kidney.  371 

vol.  i.) ;  and  paralysis  of  the  bladder  in  fracture  of 
the  spine. 

Although  the  urine  does  not  regurgitate  from  the 
bladder  into  the  ureters,  the  result  is  the  same  as  if  it 
did;  for  if  the  bladder  is  distended,  it  is  clear  the  urine 
must  be  dammed  back  upon  the  ureters  and  renal 
tubules.  The  distention  of  the  tubules  compresses 
the  vessels  that  encircle  them,  and  so  causes  a  venous 
reflux  into  the  capillaries  on  the  distal  side  of  the 
obstruction.  Again,  the  tension  may  be  raised  from 
reflex  irritation  of  some  part  of  the  urinary  tract,  by 
a  stone  in  the  bladder,  or  operations  upon  the  urethra ; 
or  the  vaso-motor  paralysis  may  be  of  central  origin, 
as  in  crushing  of  the  spinal  cord. 

Septic  'poisoning  may  take  place  :  (1)  By  spreading 
of  the  inflammation  in  the  continuity  of  the  mucous 
membrane  from  the  bladder,  ureter,  or  pelvis  of  the 
kidney  ;  (2)  by  lymphatic  absorption  from  these  parts. 

Dickinson  accounts  for  the  nephritis,  and  the 
scattered  foci  of  the  inflammation,  by  embolism  of  the 
renal  veins;  but  the  limitation  of  the  infarctions  to 
the  kidney,  and  their  shape  and  local  distribution, 
seem  opposed  to  the  theory  of  embolic  pyaemia. 

Johnson's  explanation  of  the  dissemination  of  the 
abscesses  and  patches  of  inflammation  is,  that  they 
are  due  to  rupture  of  the  renal  tubules ;  but  if  this 
were  correct,  suppuration  should  be  more  constant 
than  it  is.  My  own  view  is  that  primary  thromboses 
occur  here  and  there  in  the  obstructed  intertubular 
capillaries  (cortical  and  medullary)  and  that  the  clots 
set  up  localised  perivascular  inflammation. 

ISTephritis  following  injury  to  the  spinal  cord  may 
be  due  in  some  measure  to  trophic  lesions  of  the 
kidney. 

Oeneral  anatomy. — The  appearance  of  the 
kidney  varies,  according  to  the  cause  and  acuteness  of 
the  inflammation. 


372  Sl^J^ GICA  L    Pa  THOL  OG  \  \  [Chap.  LXXI I . 

In    clironic    interstitial     iiepbi^itis,    from 

oto  struct  ion  to  the  flow  of  urine,  tlie  effects  of 
atrophy  from  pressure  are  combined  with  those  of 
inflammation.  The  papillae  are  fl.attened.  or  entirely 
absorbed,  their  places  being  occupied  by  recesses  con- 
tinuous with  the  calyces.  In  extreme  cases  the 
pyramids  may  disappear,  and  only  a  thin  layer  of 
cortical  substance  remain. 

If  the  disease  be  limited  to  one  kidney,  every 
vestige  of  secreting  substance  may  vanish,  and  the 
capsule  may  then  retain  its  natural  outline,  or 
be  converted  into  a,  large  thin-walled  cyst.  I  have 
known  such  mistaken  during  life  for  an  ovarian 
tumour.  Atrophy  from  pressure  is  more  pronounced 
when  the  disease  is  unilateral,  for  then  the  other 
kidney  hypertrophies^  and  compensates  for  the  impaired 
function  of  the  crippled  organ,  which  is  thus  relieved 
from  its  physiological  work. 

The  effects  of  inflammation  are  :  (1)  Induration 
from  organisation  and  contraction  of  the  exudation ; 
(2)  an  irregular  nodulation  or  puckering  of  the 
surface  from  the  same  cause ;  (3)  adhesion  of  the 
kidney  to  the  capsule,  and  the  capsule  to  the  peri- 
renal fat ;  (4)  cysts  from  obstruction  of  the  secreting 
tubes. 

Acute  interstitial  nepbritis. — Here  the  kidney 
is  paler  and  softer  than  normal,  being  infi.ltrated  with 
leucocytes.  It  is  spotted  and  streaked  with  dilated 
vessels  and  minute  extravasations  both  in  the  cortex 
and  p}Tamids.  The  small-celled  infiltration  may  be 
uniform,  but  more  often  it  is  unequally  distributed, 
and  then  there  are  pale  nodules,  and  these  in  different 
stages  of  softening  and  abscess  formation.  The 
abscesses  are  usually  multiple,  but  the  greater  part  of 
the  kidney  may  be  occupied  by  one  large  abscess 
formed  by  the  coalescence  of  smaller  ones.  The  capsule 
is  adherent,  Vjut  can  be  readily  separated.     There  may 


Chap.  Lxxii.]  Surgical  Kidney.  373 

be  suppuration  beneath  the  capsule,  and  in  rare  cases 
outside  it.  Sometimes  there  are  streaks  of  suppura- 
tion within  the  pyramids. 

Acute  superveniiig  on  chronic  inflamma- 
tion.— The  appearances  will  consist  of  a  mixture  of 
the  signs  of  the  above-mentioned  types. 

Condition  of  tlie  iweters  and  pelvis. — 
Much  will  depend  upon  the  cause,  duration,  and 
intensity  of  the  disease.  When  due  to  chronic  ob- 
struction they  are  dilated,  and  their  walls  thickened 
from  inflammatory  exudation  and  muscular  hyper- 
trophy. They  are  often  strictured  from  contraction 
following  inflammation,  or  cicatrisation  of  ulcers. 
The  mucous  membrane  is  thickened  and  hypereemic. 

In  acute  cases  the  passage  contains  a  mixture  of 
pus  and  decomposed  urine,  often  tinged  with  blood 
from  capillary  haemorrhages.  They  rarely  contain 
clear  acid  urine.  The  mucous  membrane  is  swollen 
and  deeply  congested,  and  it  may  show  points  of 
capillary  extravasation,  and  slate-grey  patches  of 
degenerating  lymph. 

Microscopy. — (1)  Chronic  inflammation.  — In 
the  early  stages  there  is  congestion,  and  exudation  of 
leucocytes,  mostly  about  the  Malpighian  bodies,  the 
capsules  of  which  are  slightly  swollen  and  homogeneous. 
The  tubules  are  somewhat  dilated  (Fig.  08).  The 
epithelium  is  but  little  altered ;  at  the  most  the  cells 
are  flattened,  or  show  signs  of  commencing  proliferation 
and  cloudy  swelling. 

In  advanced  cases  there  are  wide  tracts  of  cica- 
tricial tissue,  in  which  but  few  vessels  and  no  tubules 
can  be  seen.  In  other  parts  the  disease  is  more 
active,  there  being  a  rich  infiltration  with  cells,  and 
increased  structural  change  in  the  secreting  epithe- 
lium ;  but  even  yet  some  portions  may  appear  fairly 
healthy. 

(2)  Acute  injiammation. — The   whole  organ  may 


374 


Surgical  Pathology.       [chap.Lxxii. 


be  in  a  state  of  diffuse  inflammation,  the  interstitial 
tissue  being  everywhere  crowded  with  cells.  The 
tubules  contain  altered  epithelium  and  casts  of 
fibrin,  and  even  of  leucocytes. 

But    the    disease    is    usually    concentrated    upon 
certain  points  where  nothing  can  be  seen  but  groups 


Fig.  58. — Early  stage  of  Interstitial  Nephritis  (Surgical  Kidney),  from  si 
case  of  Polypus  of  th.e  Bladder,  in  which  the  Orifices  of  the  Ureters 
were  obstructed. 

a.  Glomerulus,  tlie  vessels  are  hidden  by  corpuscles  stained  with  logwood ;  6, 
renal  tubule  :  c,  tubule  containinsr  epithelial  debris  and  desquamated  cells  ; 
d,  intertubular  tissue  increased  and  infiltrated  with  leucocytes ;  e,  capillaries. 


of  cells,  or  abscesses  in  existence  or  in  course  of 
formation.  There  is  a  zone  of  hypersemia  around  these 
foci,  and  in  some  parts  capillary  extravasation  as  well. 
State  of  the  urine. — In  chronic  cases  the 
quantity  is  increased  from  the  high  vascular  tension. 
It  may  be  double  the  normal.      It  is  pale,  and  of  low 


Chap.LXXIII.] 


Urinary  Deposits. 


375 


specific  gravity.  At  first  it  contains  but  little  or  nc 
albumin.     The  secretion  of  urea  is  diminished. 

In  aciite  cases  the  amount  of  urine  may  still  be 
greatly  above  the  normal.  In  one  instance,  supposed 
during  life  to  be  diabetes  insipidus^  I  found  post 
mortem  both  kidneys  riddled  with  abscesses.  But 
often  the  kidney  is  so  crippled  that  the  amount  of 
water  is  diminished,  and  there  is  a  daily  decrease 
in  the  secretion  of  urea.  When  cystitis  and  pyelitis 
are  present  the  urine  contains  pus  and  mucus,  and 
sometimes  blood. 

The  patients  usually  succumb  to  a  combination  of 
septicaemia  and  urinsemia. 


CHAPTER  LXXIII. 

URINARY     DEPOSITS     AND     CALCULI. 
TABLE  OF  UEINAEY  DEPOSITS. 


Name. 


a 

m  o 

C3r75 
Hi 


Chaeacteks. 


Pinkisli  yellow,  red, 
or  lateritious  (brick- 
dust)  sediment ;  urine 
scanty,  acid,  and  high- 
coloured.  The  pre- 
cipitate, "before  suh- 
siding,  forms  a  cloud 
in  the  urine,  which 
clears  off  when  heated. 

Crystalhne  form — 
uric  acid,  mostly 
rhombic  prisms  and 
plates.     "  Gravel." 


Causes, 


1.  Rapid  waste  of 
tissues,  e.g.,  as  in 
fevers ;  2,  excess  in 
nitrogenoiis  food;  3, 
dyspepsia ;  4,  ob- 
structed perspiration ; 
5,  congestion  of  the 
kidneys  (Golding 
Bird).  Also  imper- 
fect respiration.  Cold 
weather  will  precipi- 
tate urates  sometimes 
from  healthy  urine. 


Symptoms. 


Those  of  the 
causes.  Some- 
times also  a 
slight  burning 
feel  in  passing 
water. 


Urates. — Minute  spheres  with  acicular  spiculae  of  uric  acid 
projecting  from  them. 


376 


Surgical  Pathology.      [Chap.Lxxiii. 


Name. 

Chaeacters. 

Cattses. 

SyMPTOMS. 

i 

-i-i 

1 

1 
o 

Ci-ystalLiiie    forms : 
1,   quadratic    octahe- 
dra ;     2,     dumb  -  bell 
crystals. 

"  Nervous    exhaus- 
tion;" dyspepsia; 
over  -  work ;      mental 
distress ;     excess     of 
saccharine     food     or 
alcoholic  liquors. 

Those  of 
the  causes. 
Occasionally, 
loss  of  sexual 
vigour,  or  dis- 
order of  the 
sexual  func- 
tions. 

09 

<S> 

w 
o 

rd 

P4 

1.  Phosphate  of  Lime. 
— White,  cloudy  mass. 
Crystals :     spherules, 
dumb-bells,    rosettes, 
oblique         hesagocal 
prisms.     2.  PhosphsU 
of  Ammonia  and.  Mag- 
nesia {triple  phosphate). 
Crystals   (large)  :    tri- 
angular,       truncated 
prisms,       four  -  sided 
prisms,  irregular  six- 
sided  plates ;  stellate 
crystals     when     am- 
monia has  been  added. 

Alkaline  urine  is  the 
immediate  cause.     It 
is  caused  by  injuries 
and    diseases    of    the 
bladder,        especially 
paralysis  andcatarrhal 
inflammations  ;    renal 
inflammation ;    spinal 
injury      or      disease. 
Nervous  exhaustion ; 
excessive  use  of  alka- 
lies ;  the  alkalinity  of 
the  ui-ine  is    said   to 
result  from  the  meta- 
morphosis of  urea  into 
carbonate  of  ammonia. 

Urine  is 
offensive,  and 
often  contains 
muco  -pus. 
Signs  of  cau- 
sative disease. 

Small  and  delicate 
crystalline  spherules. 
Drum-sticks. 

The    causes   which 
determine  the  change 
of  urea  into  carbonate 
of  ammonia. 

No  speciiil 
symptoms 
known.  De- 
posit rare. 

8 

Urine  a    dirty -red 
colour;  after  standing, 
a  slightly  flocculent, 
brownish      sediment. 
Heat   coagulates    the 
albumen.     There  may 
be   blood    enough   to 
form  a  clot ;  then  the 
urine  is  dark  brown- 
ish-red.   Or  the  blood 
may  be  quite  unmixed 
with  the  urine. 

1.  Kidney     disease. 
Calculi,      congestion, 
inflammation,   injury, 
scurvy,  the  Bilharzia 
capensis.  Malaria  may 
cause        intermittent 
hasmaturia.         Blood 
from    the    kidney    is 
generally  mixed  urd- 
f  ormly  with  the  urine, 
andforms  blood-casts. 

2.  Bladder  affections ; 
injuries,     stone,     tu- 
mours.    Blood    from 
bladder    often    flows 
pure  after  the  urine. 

3.  Urethra:  blood 
piu'e,   and   comes  be- 
fore or  with  urine,  or 
without  urine  at  all. 

Those    of 

cause.  Use 
Heller's  test 
for  blood. 
Heat  urine, 
then  add 
KHO  and 
heat  again. 
The  phos- 
phates then 
fall  down  with 
the  colouring 
matter  of  the 
blood.  The 
sediment  has 
a  dirty  -  red 
colour  by  re- 
flected, and 
a  splendid 
blood-red  col- 
our by  trans- 
mitted Ught. 

Chap.LXXIII.] 


Urinary  Calculi. 


77 


Name. 

Characteks. 

Causes. 

Symptoms. 

Pus. 

Pus-corpuscles,  un- 
der   the    microscope, 
are     spheroidal     and 
granular.      The      pus 
generally  subsides  as 
a    dense    layer    of    a 
"  pale  greenish  cream- 
colour,"  which  can  be 
mixed         thoroughly 
with    the    urine     by 
shaking.    Not  affected 
by  acetic  acid.    Porms 
a     translucent     jelly 
when  liquor  potassse 
is  added.     The    urine 
is  albuminous. 

Abscess,  uJceration, 
or  merely  catarrh  of 
any  part  of  the  urinary 
passages.  1.  Pus  from 
the  kidneys  is  usually 
diffused     throughout 
urine  passed.     2.  Pus 
f  lom.  bladder  is  mostly 
mixed    with     mucus. 
•3.  Pus  from  an  abscess 
is  usually  variable  in 
quantity,      and      not 
equally  diffused. 

Those  of 
the  cause. 

2   • 

Epithelial  cells  lin- 
ing urinary  passages. 
See  works  on  general 
A  natomy.      Often     in 
torm  of  casts. 

Kidney  disease.  Ul- 
ceration or  catarrh  of 
bladder. 

Those  of 

cause. 

TABLE  OF  CALCULI. 


Physical  Characters,  etc. 

Chemical  Characters. 

Occurs  rarely   except    in 
children.      G-rey,      smooth, 
dusty,  non  -  laminated    ap- 
pearance. 

Soluble  in  boiling  water.  Add 
HCl  to  solution  and  you  get  a 
precipitate  of  uric  acid.  Reat 
with  potassium  carbonate  :  am- 
monia escapes.  Blow-pipe  bums 
it  away. 

< 

t3 

Smooth  or  warty.     Yel- 
lowish or    brownish.     Con- 
centric structure. 

Gives  off  no  ammonia  when 
heated  with  KHO.  Evaporate 
to  dryness  with  nitric  acid. 
Cool,  and  add  a  Httle  NH3; 
the  characteristic  deep  purpl't;- 
red  murexide  is  then  obtained. 
Blow-pipe  burns  uric  acid  away. 

6 

i 

<4-l 
O 

1 

6 

Eough,      warty,       "  mul- 
berry "'  appearance.       Very 
hard.  Dark  "blood-stained." 

Easily  soluble  in  nitric  acid. 
Boil  long  in  a  solution  of  potas- 
sium bicarbonate,  neutralise 
carefully  with  nitric  acid ;  then 
white  precipitates  can  be  formed 
with  solutions  of  lime,  lead,  or 
silver.  Blow -pipe  reduces  it, 
urst  to  calcium  carbonate,  then 
to  quick-lime.  Heat  on  platinum 
foil  and  it  chars.  Then  add 
HNO3  and  it  f  ftervesces. 

378 


Surgical  Pathology.      [Chap.Lxxiii. 


o 


rrt     1    DO   ?i 


Physical  Characters,  etc. 


Has  a  wavy  appearance, 
especially  when  fractured. 
Changes  colour  with  age 
from  pale  yellow  to  brown, 
grey,  or  green.  Extremely 
rare.     Contains  sulphur. 


Section,  lustrous  bright 
brown.  Most  extremely 
rare. 


Chemicai  Characters. 


Dissolves,  in  great  part,  in 
ammonia  :  its  solution  then  de- 
posits, by  spontaneous  evapora- 
tion, six  -  sided  prismatic  and 
tubular  crystals.  Dissolve  in 
strong  caustic  potash.  Boil,  and 
add  a  little  solution  of  lead  ace- 
tate :  a  black  precipitate  of  sul- 
phide of  lead  falls. 


Chalky,  soft,  brittle,  lami- 
nated. 


Has  a  peculiar  deep  yellow 
colour,  when  its  solution  in 
nitric  acid  is  evaporated  to  dry- 
ness :  characteristic. 


"  Fusible  calculus  :  "  melts  in 
the  blow-pipe  flame.  Dissolve 
in  nitric  acid  and  add  excess  of 
ammonia  :  whiite  precipitate.* 


Oall  stones  compa^red  with  urinary 
calculi. — (1)  G-all  stones  are  mucli  lighter,  the 
majority,  when  dry,  floating  in  water  ;  (2)  they  feel 
greasy  to  the  touch  ;  (3)  the  colour  of  many  differs 
from  that  of  any  known  form  of  urinary  calculus ;  (4) 
the  shape  is  often  suggestive,  sometimes  conclusive,  of 
their  nature.  The  presence  of  many  facets  is  in 
favour  of  biliary  origin.  If  large  and  barrel-shaped, 
with  terminal  facet,  there  can  be  no  doubt  that 
they  are  not  only  gall  stones,  but  that  they  were 
retained  for  a  long  time  in  the  gall  bladder,  and  were 
multiple.  When  granular  on  the  surface  they  look 
like  aggregations  of  minute  calculi,  which  in  fact  they 
often  are.  (5)  On  fracture,  glistening  flakes  or  scales 
of  cholesterine  may  be  very  obvious. 

*  Copied  by  permission  from  Keetley's  "Index  of  Surgery." 


379 


CHAPTER  LXXIY. 

ULCEES    OF    THE    ANUS    AND    RECTUM. 

Ulcers  about  the  anus.  —  The  principal 
varieties  are:  (1)  Simple  fissure;  (2)  syphilitic  mucous 
tubercles;  (3)  epithelioma;  (4)  ulcerated  piles;  (5) 
ulcers  in  connection  with  fistulous  openings  and 
operation  wounds. 

Primary  venereal  sores  are  occasionally  seen  in 
this  situation. 

Painful  fissure  of  the  anus  may  exist  alone,  but  it 
frequently  starts  from  the  base  of  a  pile.  It  probably 
commences  in  an  abrasion  of  the  mucous  mem- 
brane. The  nerve-fibres  are  subject  to  more  or  less 
constant  irritation,  from  contraction  of  the  sphincter, 
and  the  tension  upon  them  is  greatly  increased  by  the 
act  of  clefgecation.  It  seems  likely  that  the  terminal 
twigs  are  exposed  in  the  floor  of  the  ulcer.  It  may  be 
that  they  are  constricted  by  the  contraction  of  inflam- 
matory lymph.  An  incision  made  in  the  axis  of  the 
fiijsure  divides  some  of  the  muscular  fibres  of  the 
sphincter,  and  with  them  the  nerves.  A  certain 
amount  of  physiological  rest  is  given  to  the  parts,  and 
tills  promotes  healing. 

E pithelioriiatous  ulceration  commences  at  the  junc- 
tion of  the  skin  with  the  mucous  membrane.  The 
base  of  the  ulcer  is  granular  or  tuberculated,  and 
greatly  indurated.  On  rectal  examination  it  will 
usually  be  found  that  the  structures  beyond  the  anus 
are  invaded,  and  the  extent  of  this  may  be  sufiicient 
in  itself  to  exclude  ulcerated  piles. 

External  piles  are  rarely  ulcerated  beyond  the 
surface ;    and    when   internal   piles    are    extensively 


o 


So  Surgical  Pathologw      [Chap.  lxxiv. 


destroyed  it  is  by  a  comlDined  process  of  ulceration 
and  gangrene,  their  bases  being  strangulated  by  the 
sphincter  ani.  Such  a  protruded  mass  shows  an  ab- 
sence of  marked  induration  ;  and  there  is  no  infiltra- 
tion of  the  tissues  about  the  base,  which  is  limited 
by  the  folds  of  the  tliickened  anal  mucous  membrane 
and  skin. 

Anal  fistulce  sometimes  refuse  to  heal  after  being 
laid  open.  Then  the  margins  and  base  of  the  ulcer 
become  indurated,  and  the  papillse  of  the  surrounding 
skin  hypertrophied.  Tliis  gives  a  warty  appearance, 
something  like  epithelioma.  But  in  epithelioma  the 
induration  is  greater,  and  there  is  more  outgrowth, 
the  constructive  process  outstripping  the  destructive. 
The  direction  of  an  ulcer  left  after  operation  for 
fistula  is  strongly  suggestive  of  its  origin.  It  must 
be  remembered  that  long-continued  irritation  of  a 
simple  ulcer  may  cause  it  to  take  on  a  malignant 
character. 

Ulcers  of  tlie  rectuni. — Those  of  greatest 
surgical  importance  are  (1)  simple;  (2)  syphilitic;  and 
(3)  malignant. 

Simple  rectal  ulcer  may  be  due  to  traumatic  or 
spontaneous  irritation;  but  their  origin,  is  generally 
involved  in  obscurity,  since,  when  small  and  free  from 
the  disturbing  influence  of  the  sphincter  they  give 
but  little  trouble.  They  are  mostly  situated  ^vithin 
the  lower  two  inches  of  the  rectum.  The  floor  or  base 
shows  but  little  induration ;  in  fact,  it  may  almost  be  as 
free  from  it  as  the  healthy  mucous  membrane ;  but 
the  margin  is  usually  defined.  An  important  sign, 
and  one  of  especial  value  in  the  diagnosis  of  recent 
ulceration,  is  the  bleeding  occasioned  by  digital 
examination.  This  is  usually  slight,  but  one  does 
not  meet  ^vith  it  when  the  mucous  membrane  is  intact. 
Kectal  ulcers  are  slow  to  heal,  on  account  of  the 
muscular  contractions  of  the  bowel,  and  the  irritation 


Chap.  Lxxiv.]    Ulcers  of  the  Rectum.  -^Zv 

caused  by  the  passage  of  fseces.  Whilst  cicatrisation 
goes  on  at  one  part  the  ulcer  often  spreads  at  another. 
Other  things  being  equal,  the  liability  to  stricture  is 
proportionate  to  the  duration  of  the  ulceration.  As 
the  destructive  process  tends  to  spread  in  a  circular 
direction,  the  resulting  stricture  is  crescentic  or 
annular. 

Syphilitic  rectal  ulcer  is  in  most  cases  a  tertiary 
lesion  ;  but  it  sometimes  appears  during  the  secondary 
symptoms.  Like  other  ulcers  of  the  rectum,  it  is 
usually  within  reach  of  the  finger.  The  occasional 
existence  of  scars  about  the  anus  has  led  some 
surgeons  to  conclude  that  the  ulceration  commences 
externally,  and  afterwards  involves  the  rectum.  This 
view  at  first  sight  appears  strengthened  by  the  fact 
that  syphilitic  disease  of  the  rectum  is  many  times 
more  frequent  in  women  than  in  men.  (In  women 
there  is  a  greater  liability  of  ulceration  spreading 
from  the  genitals  to  the  anus  than  in  men.)  The 
foregoing  explanation  may  be  true  to  a  certain  extent, 
but  it  does  not  apply  to  the  maj  ority  of  cases  in  which 
the  ulceration  undoubtedly  begins  internal  to  the 
sphincter.  It  is  by  no  means  rare  for  an  inch  or  so 
of  healthy  mucous  membrane  to  intervene  between 
the  anus  and  the  seat  of  the  disease.  Reflex  or 
sympathetic  irritation  of  the  rectum  from  disorders  of 
the  generative  organs,  and  pi'otracted  constipation, 
cannot  go  for  much  in  explaining  the  greater  liability 
to  syphilitic  ulceration  of  the  rectum  in  women ;  for 
the  same  conditions  would  also  predispose  to  malignant 
disease,  and  this  is  more  common  in  males. 

There  is  no  certain  sign  by  which  we  can  tell 
simple  from  syphilitic  ulceration  of  the  rectum,  so  we 
always  appeal  to  the  history  of  the  case,  and  seek  for 
concomitant  evidence  of  syphilis  to  make  the  diagnosis 
complete.  Speaking  generally,  it  may  be  said  that 
syphilitic  ulceration  is  more  extensive,  more  rapid  in 


382  Surgical  Pathology.       [Chap.  lxxv. 

its  development,  and  more  amenable  to  specific 
remedies,  than  simple  inflammatory  erosion. 

At  the  same  time,  it  is  ver}^  inveterate,  and  gives 
rise  to  great  discomfort  from  the  pain,  profuse  dis- 
charge, and  the  secondary  troubles  consequent  on 
stricture. 

Malignant  rectal  ulcer. — Every  form  of  malignant 
disease  that  attacks  the  rectum  sooner  or  later  causes 
ulceration.  This  either  begins  at  the  anus,  from  the 
disintegration  of  epithelial  cancer,  or  quite  clear  of 
the  orifice  in  connection  with  columnar  epithelioma, 
or  scirrhus,  or  less  commonly  sarcoma.  The  base  of 
the  ulcer  is  very  indurated,  and  of  unequal  depth  at 
different  parts,  depressions  alternating  with  hard 
nodular  elevations.  The  margin  has  an  irregular 
outline.  It  is  raised,  and  the  tissues  are  infiltrated 
with  growth  for  some  distance  beyond  it.  The  dis- 
charge consists  of  pus,  slimy  mucus,  blood,  and  the 
debris  of  the  new  formation.  It  is  very  foul  from 
decomposition,  and  the  foetor  is  in  proportion  to  the 
rate  of  destruction  of  tissue. 

Malignant  ulcer  of  the  rectum  has  a  proclivity  for 
the  male  sex.  It  is  met  with  chiefly  beyond  mid- 
adult  life.     Stricture  is  a  certain  sequel. 


CHAPTER  LXXY. 

STRICTURE    OP    THE    RECTUM. 

It  has  been  already  noted  that  simple,  syphilitic, 
and  malignant  ulceration  entails  constriction  of  the 
calibre  of  the  bowel.  In  the  two  former  the  cicatrisa- 
tion is  purely  inflammatory  in  nature.  In  cancerous 
disease  it  is  partly  due  to  contraction  of  the  fibrous 


Chap.  Lxxv.i  Stricture  of  the  Rectum.  383 

stroma,  the  same  as  retraction  of  the  nipple  from  atro- 
phying scirrhus  of  the  mamma. 

Obstruction  from  cancerous  stricture  is  increased 
by  projecting  nodules  of  the  growth. 

Stricture  of  the  rectum,  independent  of  ulceration, 
is  very  rare,  but  it  may  arise  from  the  shrinking  of 
plastic  lymph  effused  into  the  submucous  tissue,  or 
from  traction  on  the  gut  by  the  organised  products  of 
pelvic  cellulitis.  It  is  difficult  to  conceive  how  long- 
continued  irritation  can  lead  to  localised  annular 
hypertrophy  of  the  muscular  coat  of  the  rectum, 
without  causing  at  the  same  time  ulceration  of  the 
mucous  membrane,  or  inflammatory  thickening  of  the 
cellular  tissue  beneath  it. 

Stricture  may  be  simulated  by  an  unusually- 
developed  fold  or  valve  of  Houston. 

The  stricture  is  crescentic  or  annular,  according  as 
the  disease  which  causes  it  involves  a  part  or  the 
whole  of  the  circumference  of  the  orut.  So  Ions:  as  a 
segment  of  the  circle  of  mucous  membrane  remains 
free,  the  contraction  is  not  likely  to  give  rise  to 
dangerous  obstruction,  save  in  the  case  of  malignant 
disease,  where  a  mass  of  new  growth  may  block  the 
passage  at  the  seat  of  stricture. 

Effects  upon  the  too^  el  above  and  below 
the  stricture. — The  calibre  of  the  gut  for  a  lonjr 
way  on  the  proximal  side  (it  may  be  through  the 
whole  or  greater  part  of  the  intestine)  is  very  much 
dilated,  and  the  muscular  coat  is  enormously  liy^er- 
trophied  to  compensate  for  the  increased  resistance  to 
its  action.  But,  in  spite  of  the  hypertrophy,  the 
bowel  is  distended  with  flatus,  and  scybalous  masses 
collect  in  the  upper  part  of  the  rectum  and  in  the 
colon.  Co'iistipation  is  the  natural  result,  but  this 
may  be  masked  by  constant  or  periodical  diarrhoea 
("the  diarrhoea  of  constipation")  ;  for,  in  addition  to 
the  discharge  from  the  ulcerated  surface,  the  mucou.«* 


384  Surgical  Pathology.       [Chap. lxxv. 

membrane  is  fretted  by  incarcerated  faeces,  and 
so  kept  in  a  state  of  congestion  and  catarrh. 
From  time  to  time  a  quantity  of  fluid  is  poured 
out  to  relieve  the  over-distended  vessels.  The  har- 
dened faeces  are  softened  and  diminished  in  size,  they 
being  churned,  as  it  were,  in  the  exudation.  ,  Then 
there  comes,  perhaps,  a  period  of  quiescence,  to  be 
followed,  in  turn,  by  another  attack  of  diarrhoea. 
The  important  point  to  note  is  that  all  this  time  con- 
stipation may  exist. 

Perforation  of  the  howel  sometimes  takes  place  at 
a  distance  from  the  stricture,  but  more  commonly  in 
its  proximity. 

The  perforation  is  either  purely  ulcerative,  or 
ulcerative  and  gangrenous.  I  once  performed  colo- 
tomy  for  obstruction  from  malignant  stricture  of  the 
rectum.  At  the  post-mortem  it  was  found  that  a 
mass  of  hardened  faeces  had,  by  its  pressure,  led  to 
death  of  a  considerable  portion  of  the  wall  of  the 
caecum,  and  consequent  perforation  and  peritonitis. 
The  patient  bore  a  healthy  scar  of  amputation  of  the 
breast  practised  for  scirrhus  four  years  previously. 

The  perforation  may  take  place  into  the  peri- 
toneum, or  into  an  adjoining  viscus,  or  it  may  set  up 
abscess,  and  this  may  remain  localised,  or  travel 
along  the  bowel  and  open  externally.  In  the  last- 
mentioned  event  the  fistula  serves  as  an  escape-pipe 
for  the  matters  pent  up  above  the  stricture. 

If  the  stricture  is  an  inflammatory  one,  the  ulcera- 
tion often  heals  below  whilst  it  spreads  above  it,  for 
the  distal  portion  of  bowel  is  in  a  state  of  rest  com- 
pared with  the  proximal.  Malignant  ulcer  nevei 
completely  cicatrises  on  either  side  of  the  stricture. 
The  traction  exerted  by  the  stricture,  and  the  pressure 
of  the  exudation  about  it,  cause  obstruction  to  the 
circulation  through  the  haemorrhoidal  veins;  hence 
piles  are  likely  to  form.     These,  when  indurated,  as 


Chap.  Lxxvi.]   Tumours  of  the  Rectvm.  385 

they  often  are,  may  be  mistaken  for  cancerous  nodules, 
especially  as  they  are  associated  with  ulceration  and 
stricture. 

Stricture  entails  straining  at  defsecation,  and  the 
mechanical  effects  of  this  are  patulous  anus^  and  in 
the  female  procidentia  uteri,  cystocele,  and  rectocele. 


CHAPTER  LXXVI. 

TUMOURS    OF    THE    RECTUM. 

Malignant  tumours  of  the  rectum  comprise 
certain  forms  of  cancer  and  sarcoma.  It  is  customary 
to  speak  of  two  varieties  of  rectal  cancer,  epithelioma, 
and  scirrhus.  With  regard  to  epithelioma  of  the  anus, 
there  can  be  no  difference  of  opinion  as  to  its  origin, 
structure,  and  place  in  the  nomenclature  of  new 
growths.  It  commences  at  the  junction  of  the  skin 
with  the  mucous  membrane,  and  spreads  deeply  and 
widely  in  the  surrounding  tissues.  It  is  essentially 
a  new  formation  on  the  type  of  squamous  epithelium, 
and  it  has  the  characters  common  to  epithelioma  of 
the  lip,  tongue,  and  cutaneous  surface,  the  most 
striking  feature  being  the  presence  of  globes  or  pearls 
made  up  of  concentrically  laminated  cells."  As  the 
growth  encroaches  on  the  mucous  membrane,  where 
the  epithelium  is  columnar,  cells  of  transitional  form 
may  be  observed. 

The  inguinal  glands  are  infected  from  the  outward 
part  of  the  growth,  and  the  pelvic  and  lumbar  from 
the  rectal. 

On  the  assumption  that  all  cancers  start  fi-om 
pre-existing  epithelium,  it  would  be  illogical  to  assert, 
on  strict  pathological  grounds,  that  there  is  a  clear 
distinction  betw^een  scirrhus,  and  columnar  epithelioma 


386 


Surgical  Pathology.      LChap.  lxxvi. 


of  tlie  rectum.  It  is  true  the  epithelial  cells  lining 
or  filling  the  alveoli  do  not  always  preserve  the 
cylindrical  shape  in  its  integrity,  being  sometimes 
subcolumnar,  or  more  or  less  angular,  or  rounded. 
The  stroma,  too,  varies  greatly  in  amount  and  regu- 
larity of  distribution. 

There  can  be  no  objection  to  retaining  the  terms 
"  scirrhus  "  and  "  epithelioma 

1 


so  long  as  the  central 


Fig.  59.  — Columnar  Epithelioma  of  Eectum. 

a.  Acinus  lined  by  columnar  epithelium  ;  5.  acinus  from  which  the  epithelium 
has  dropped  out  during  the  preparation  of  the  section  ;  c,  interaciuose 
stroma,  formed  of  delicate  fibres  strewn  with  indifferent  cells,    x  265. 

idea  of  epithelial  origin  is  kept  in  view.  One  thing  is 
certain,  rectal  cancers  proper  do  not  show  a  tendency 
to  develop  squamous  epithelium  ;  nor  would  this  be 
expected,  when  one  considers  that  the  physiological 
type  of  the  cells  is  columnar.  Rectal  cancers  are 
often  so  perfectly  glandular  in  their  minute  structure 
that  it  is  difficult,  from  a  microscopical  examination 
alone,  to  distinguish  them  from  adenomas.  ( Vide 
Figs.  59  and  75.)  But  should  a  doubt  arise  as  to  the 
malignancy  of  a  given  specimen,  it  can  be  dispelled 
by  the  knowledge  that  the  mode  of  growth  is  infil- 
trating and    deeply  destructive.     The    same  is    true 


Chap.  Lxxvi.]  Sarcoma  of  the  Rectum.  387 

concerning  simple  villous  tumour  and  villous  cancer 
of  the  bladder  (q-v.).  "The  boundaries  between 
simple  papilloma  and  villous  cancer  mav  be  just  as 
difficult  to  define  as  those  between  adenoma  and 
carcinoma  "  (Billroth).  When  the  glandular  arrange- 
ment is  well  defined  these  rectal  cancers  are  appro- 
priately designated  "adenoid."'  It  will  generally  be 
found  that  the  superficial  portions  of  the  tumour 
conform  more  to  the  likeness  of  the  normal  anatomy 
of  the  mucous  membrane  than  do  the  deeper. 

The  naked-eye  and  microscopical  appearances  of 
cancerous  disease  of  the  rectum  vary  as  the  rate  of 
cell  multiplication  and  the  relative  extent  of  the 
funj^atin^  and  infiltratinoj  modes  of  growth.  In  some 
cases  there  is  a  marked  tendency  to  invade  the  sub- 
mucous coat,  and  to  develop  a  quantity  of  fibrous 
tissue.  The  latter,  as  it  undergoes  cicatricial  con- 
traction, gives  rise  to  great  induration,  and,  as  the 
hardening  and  proliferation  are  not  uniformly  diftused, 
the  surface  is  tuberculated. 

On  the  other  hand,  the  interstitial  tissue  may  be 
scanty,  and  richly  strewn  with  indifi'erent  cells,  whilst 
the  epithelial  formation  is  abundant.  At  the  same 
time,  the  growth  may  sjDread  more  in  the  direction  of 
the  lumen  of  the  bowel  than  in  its  walls,  and  conse- 
quently assume  a  tuberous  form. 

The  fonner  varietv  is  tliat  usuallv  recognised  as 
"  scirrhus,"  the  latter  as  "  adenoid  cancer "  or 
"  columnar  epithelioma  ;  "  but  between  the  two  there 
are  tumours  that  represent  every  gradation. 

/Sarcoma  of  the  rectum  is  less  common  than 
cancer.  It  either  invades  the  bowel  from  without,  or 
starts  in  the  submucosa.  Histologically  it  consists  of 
round  and  spindle  cells  and  a  variable  amount  of 
mucous  tissue  (myxo-sarcoma).  Clinically  and  patho- 
logicallv  it  conforms  to  the  laws  regulatincr  the  fn*owth 
of  sarcomatous  tumours  in  general. 


2,SS  Surgical  Pathology.      [Chap. lxxvi. 

Innocent  tumours  of  the  rectum  are  met 

with  chiefly  in  the  polypoid  form,  benign  intramural 
growths  being  exceedingly  rare.  They  are  more  com- 
mon in  children  than  in  adults,  contrasting  in  this 
way  with  malignant  disease.  The  base  of  attachment 
is  in  most  cases  within  reach  of  the  finger.  Every 
variety  of  simple  polypus  may  be  found.  The 
following  may  be  enumerated  :  (1)  Tibro-glandular,  or 
adenomatous ;  (2)  villous ;  (3)  vascular ;  (4)  myxo- 
matous ;  (5)  warty.  The  foregoing  classification  is 
based  partly  upon  the  coarse  anatomy  and  partly 
upon  the  microscopical  structure  of  rectal  polypi. 

Adenomatous  polypus  occurs  as  a  soft,  fleshy  mass, 
with  a  rather  broad  peduncle.  The  interacinose  tissue 
consists  of  a  more  or  less  gelatinous  ground  substance, 
through  which  is  woven  a  network  of  fibres,  cell 
ramifications,  and  blood-vessels.  In  some  cases  it  is 
exactly  like  the  tissue  that  makes  up  the  entire  mass 
of  a  simple  mucous  polypus  ;  in  others  it  is  more 
densely  fibrous.  It  is  richly  vascular  and  cellular. 
But  the  characteristic  feature  is  the  presence  of  glan- 
dular acini  and  tubular  recesses  lined  with  columnar 
epithelium.  The  adenoid  tracts  are  circular,  oval, 
straight,  or  sinuous,  and  are  distributed  singly  or  in 
racemose  clusters.  The  surface  of  the  tumour  is 
covered  with  the  same  kind  of  epithelium  that  lines 
the  acini  and  crypts  (Fig.  75). 

Villous  polyf)us  is  seen  as  an  arborescent,  leafy,  or 
filiform  outgrowth,  sessile,  or  distinctly  pedunculated. 
Histologically  it  is  composed  of  connective  tissue  in 
various  stages  of  development — embryonic,  mucous,  and 
fibrous.     The  surface  epithelial  cells  are  columnar. 

Vascular  polypus  is  almost  confined  to  early  life ; 
hence  it  is  commonly  known  as  the  "  vascular  polypus 
of  children."  It  is  found  singly  or  in  groups.  It  is 
often  no  larger  than  a  pea  or  bean.  It  has  a  florid 
appearance,  something  like  a  raspberry.     Structurally 


Chap. Lxxvii.]  Prolapse  of  the  Rectum.  389 

it  is  made  up  of  a  delicate  stroma  of  connective  tissue, 
which  supports  the  numerous  large  capillary  blood- 
vessels. It  is  very  similar  to  the  small  caruncular 
growths  about  the  orifice  of  the  female  urethra.  It 
is  very  liable  to  bleed. 

Myxomatous  or  gelatinous  polyiius  has  the  same 
structure  as  common  nasal  polypus,  with  the  exception 
that  the  epithelium  is  not  ciliated. 

Warty  'polypus  is  so  seldom  met  with  that  a 
detailed  description  is  not  needed.  The  mucous  mem- 
brane of  the  rectum  over  a  considerable  area  has  been 
found  covered  with  small  papillomatous  proliferations. 

The  so-called  "  fibrous  polypus "  is  generally  a 
villous  growth,  or  fibro-glandular  tumour,  as  above 
described. 

The  chief  symptoms  of  rectal  polypi  are  tenesmus, 
sanguineous  and  mucous  discharge,  prolapse  of  the 
bowel,  and  reflex  disturbance  of  the  genito-urinary 
organs,  such  as  irritation  about  the  penis  and  frequent 
micturition. 


CHAPTER   LXXVII. 

PROLAPSE,  HEMORRHOIDS,  AND   FISTULA. 

Prolapse  of  the  rectum. — In  slight  cases  the  loose 
submucous  tissue  just  above  the  anus  is  stretched, 
and  this  allows  a  ring  or  fold  of  mucous  membrane  to 
protrude  ;  but  a  more  important  variety  is  that  where 
the  entire  thickness  of  the  gut  becomes  prolapsed. 

The  causes  are  the  same  in  each  case,  viz.,  laxness 
of  the  sphincter  ani  and  muscular  coat  of  the  bowel, 
and  mechanical  strain  upon  the  parts  from  long- 
continued  or  oft-repeated  tenesmus.  The  irritation 
may  arise  from  some  rectal  disorder,  such   as  piles. 


390  Surgical  Pathology.      [Chap.LXXvii 

polypi,  or  ascarides  ;  or,  reilexly,  from  phimosis,  stone 
ill  the  bladder,  enlarged  prostate,  or  stricture.  But, 
apart  from  reflex  contraction,  voluntary  efforts  to 
overcome  obstruction  to  the  flow  of  urine  entail  a 
bearing  down  upon  the  rectum. 

In  women,  the  recto-vaginal  sejDtum  may  yield, 
and  form  the  wall  of  a  broad-mouthed  cul-de-sac 
(rectocele).  The  causes  of  this  are,  loss  of  support 
from  rupture  of  the  perineum,  and  straining  at  stool. 
{Vide  Stricture  of  the  rectum.) 

HceifnoQ^r holds. — The  essential  pathology  of  piles 
is  a  dilatation  of  the  hsemorrhoidal  vessels,  and  chiefly 
of  the  veins.  When  the  vascular  dilatation  is  limited 
to  the  skin  around  the  anal  orifice,  the  piles  are 
called  "external;"  and,  when  it  is  confined  to  the 
mucous  membrane  of  the  rectum,  they  are  termed 
"internal."  It  very  frequently  happens  that  the  two 
co-exist ;  but  even  then  the  division  is  marked  by  a 
shallow  groove  on  the  surface,  which  serves  as  a  guide 
to  the  suro-eon  as  to  what  should  be  lis^atured  and 
what  excised  in  operations  for  the  cure  of  the  disease. 

In  external  piles  the  veins  are  dilated  and  their 
walls  thickened,  and  the  perivascular  connective  tissue 
is  hypertrophied  and  indurated.  The  result  of  these 
structural  alterations  is  the  formation  of  firm  nodular 
blueish-white  masses,  covered  with  thickened  skin. 

Loose  folds  of  integument,  radiating  from  the 
anus,  are  frequently  seen  apart  from,  or  in  continua- 
tion of,  the  hsemorrhoidal  tumours. 

In  internal  piles  the  same  morbid  changes  are 
observed,  but  the  arteries  and  capillaries  often  parti- 
cipate largely  in  the  process. 

On  account  of  the  arterio-capillary  dilatation,  the 
lack  of  surface  support  from  chronic  inflammatory 
induration  of  the  mucous  membrane^  and  the  liability 
to  injury  from  the  jiassage  of  hardened  faeces,  internal 
piles  are  prone  to  bleed. 


Chap.LXXVIL]  FiSTULA    IN  AiVO.  39! 

Ill  those  cases  where  the  ectasia  mainly  afifects  the 
veins,  the  piles  are  often  pedunculated,  and  they 
present  a  somewhat  livid  appearance.  Where,  on  the 
other  hand,  the  ai-teries  and  capillaries  are  extensively 
enlarged,  the  piles  are  brighter  in  colour  and  more 
sessile. 

Anything  that  serves  to  determine  blood  to  the 
part,  or  mechanically  prevents  its  return,  conduces 
to  the  development  of  hemorrhoids.  Chemical  or 
mechanical  irritation  of  the  rectum,  and  plethora  of  the 
portal  circulation,  are  the  principal  points  to  be  borne 
in  mind.  The  ultimate  causes  are  constipation, 
straining  on  account  of  diihcult  micturition,  and 
alcoholism  and  high  feeding.  Cirrhosis  of  the  liver  is 
an  intermediate  factor.  Internal  and  external  piles 
may  become  inflamed ;  and  internal  piles  strangulated 
by  the  sphincter  ani.  When  inflamed  they  are  very 
tense,  livid,  and  painful.  The  veins  are  thrombosed, 
and  their  walls  and  the  connective  tissue  around  are 
infiltrated  with  lymph  and  leucocytes. 

Speaking  generally,  we  may  say  that  the  morbid 
anatomy  of  piles  consists  mainly  of  venous  dilatation 
and  varicosity ;  and  that  phlebitis  is  the  essence  of 
their  inflammation. 

Fistula  in  ano. — A  complete  fistula  has  one 
orifice  on  the  cutaneous  surface  and  the  other  in  the 
bowel.  Of  incomplete,  or  blind  fistulae,  there  are  two 
varieties,  internal  and  external.  The  former  com- 
municates only  with  the  rectum  ;  the  latter  opens  by 
the  side  of  the  anus.  An  incomplete  fistula  of  either 
kind  may  become  complete,  and  vice  versa. 

As  a  rule  the  internal  opening  is  just  above  the 
sphincter,  and  the  external  near  its  outer  border  ;  and 
the  passage  between  them  pretty  direct.  But  there 
are  many  exceptions;  e.g.,  the  sinus,  after  "coasting 
the  bowel,"  may  end  on  the  opposite  side  ("horse- 
shoe fistula ")  ;    or  from  inefiiciency  of  drainage  the 


392  Surgical  Pathology.    [Chap.  lxxviii. 

original  tract  may  give  off  diverticula,  or  be  extended 
for  a  long  distance  above  the  upper  opening,  or  out- 
wards from  the  external.  In  stricture  of  the  rectum 
ifl-v.)  the  fistula  joins  the  proximal  dilated  portion  of 
the  bowel. 

Suppuration  is  the  means  by  which  the  fistula  is 
established.  It  may  commence  in  an  extra-rectal 
abscess,  or  in  an  ulcer  of  the  mucous  membrane. 

The  cause  of  such  ulcer  or  abscess  is  either 
constitutional  or  local.  The  frequent  association  of 
fistula  and  phthisis  suggests  an  origin  in  scrofulous 
inflammation.  Irritation  from  hardened  faeces,  or  a 
foreign  body,  although  it  cannot  often  be  proved  to 
be  an  exciting  cause,  may  still  be  such.  I  once 
removed  a  fishbone  which  had  transfixed  the  bowel 
immediately  above  the  internal  sphincter  ;  one  end 
could  be  felt  per  rectum,  and  the  other  by  means  of  a 
probe  passed  through  the  outer  orifice  of  the  fistula. 

With  regard  to  the  propriety  of  an  operation,  it 
may  be  said  that  it  turns  upon  the  chances  of  the 
wound  healing  rather  than  upon  the  influence  that  a 
fistula  has  been  supposed  to  have  in  checking  the 
progress  of  tubercular  disease  of  the  lungs. 

Experience  teaches  that  the  getting  rid  of  a  sup- 
purating cavity  or  tract  has  a  decidedly  beneficial 
efiect  upon  a  patient  suffering  from  phthisis. 


CHAPTER   LXXYIIL 

PERITOXITIS. 


Peritonitis  is  not  common  except  as  the  result  of 
injury  or  some  other  source  of  local  irritation,  such  as 
substances   derived  from   rupture   of  the   underlying 


Chap.  Lxxviii.]  Peritonitis.  393 

viscera  or  pathological  cavities,  or  diseased  states 
spreading  by  continuity  ;  e.g.^  cancer  of  the  liver,  and 
typhoid  and  tubercular  inflammation  of  the  intestines. 
Peritonitis  is  usually  described  as  acute  or  chronic, 
but  between  the  two  forms  there  are  many  inter- 
mediate degrees  of  intensity. 

Chronic  peritonitis  is  either  general  or  partial. 
When  general  it  is  caused  by  Bright's  disease,  or 
disseminated  cancer,  or  tubercle.  Partial  peritonitis 
occurs  in  connection  with  localised  disease  of  the 
structures  beneath  the  serous  membrane,  e.g..,  an  ulcer 
of  the  stomach  or  intestine,  or  inflammation  of  the 
pelvic  organs  ;  or,  as  the  consequence  of  long-continued 
friction,  notably  in  old  hernial  sacs.  The  lymph 
poured  out  from  the  vessels  organises  to  connective 
tissue,  which  binds  together  adjacent  parts,  and,  con- 
tracting, causes  constriction  of  the  hollow  viscera  ; 
and  various  displacements.  By  continued  stretching 
the  adhesions  may  be  elongated  into  fibrous  bands, 
beneath  which  a  portion  of  the  bowel  may  slip,  and 
become  strangulated.  The  peritoneum  is  greatly 
thickened,  as  is  seen  in  hernial  sacs,  where  the 
contents  have  been  allowed  to  remain  habitually 
prolapsed. 

Aciite  peritonitis  is  set  up  by  rupture,  or 
ulcerative  perforation  of  some  viscus,  e.g..,  the  bladder, 
or  intestine ;  or  by  bursting  of  a  hydatid  cyst,  or 
localised  abscess  ;  or  by  a  wound  from  without,  as  in 
the  operations  of  gastrostomy,  gastrotomy,  and 
herniotomy. 

The  pathological  appearances  vary  greatly  in 
different  cases  according  to  the  rapidity  of  the  process, 
the  general  health  of  the  patient,  and  as  to  whether 
the  peritoneum  be  healthy,  or  altered  in  structure  by 
previous  disease.  One  result  of  chronic  thickening  of 
the  membrane  is  to  diminish  the  liability  to  acute 
general  inflammation,  so  that  the  sac  of  an  old  hernia 


394  Surgical  Pathology.    [Chap,  lxxviii. 

may  be  ojoened  with  less  risk  than  that  of  a  recent 
one. 

The  inflammation  is  termed  serous,  plastic,  puru- 
lent, or  hgemorrhagic,  according  to  the  prevailing 
product  of  exudation  ;  the  same  as  happens  in  pleurisy 
and  pericarditis. 

In  surgical  practice  it  is  usual  to  speak  of  two 
varieties  :  sthenic  ;  and  asthenic,  or  latent. 

In  acute  sthenic  peritonitis  the  signs  and  symptoms 
are  most  pronounced.  They  are  :  severe  pain  ;  great 
abdominal  tenderness ;  marked  tympanites ;  knees 
drawn  up  to  relax  the  abdominal  muscles ;  fast,  wiry 
pulse ;  and  high  fever. 

In  the  latent  or  asthenic  form  there  are  the  same 
physical  conditions  that  underlie  the  above-mentioned 
symptoms,  but  the  depressed  or  exliausted  state  of 
the  patient  prevents  a  general  response  to  the  absorp- 
tion of  the  products  of  inflammation,  and  the 
irritation  of  a  wide  tract  of  visceral  nerves.  One  is 
often  struck  by  the  contrast  offered  by  the  comparative 
immunity  from  suffering,  and  the  revelations  of  the 
post-mortem  room.  An  old  man  who  has  been 
operated  upon  for  strangulated  hernia  may  never  rally 
sufficiently  to  manifest  by  general  signs  the  pro- 
found structural  alterations  going  on  in  the  perito- 
neum. 

Morbid  anatoaiiy. — Unless  the  peritonitis  be 
caused  by  some  irritant  fluid  poured  more  or  less 
over  the  whole  surface,  the  inflammatory  changes  are 
most  marked  at  the  seat  of  the  original  injury  ;  e.g., 
whilst  there  is  a  copious  deposit  of  lymph,  and  it  may 
be  pus,  upon  and  about  the  contents  of  a  hernial  sac 
after  reduction  ;  the  parts  more  remote  may  be  only 
lightly  glued  together  by  a  scanty  fibrinous  exudation. 
In  some  cases,  however,  and  especially  where  a  large 
wound  has  been  inflicted,  and  the  inflammation  is  of 
a  septic  nature,  the  inflammation  spreads  with  great 


Chap.  LXXVIIL]  PERITONITIS.  395 

rapidity,  and  soon  becomes  widely  diffused;  e.g.^  after 
ovariotomy. 

The  first  stage  is  that  of  vascular  injection;  the 
subserous  vessels  are  dilated^  then  there  is  exudation 
upon  the  surface  of  the  membrane  and  into  its  inter- 
stices. As  the  natural  secretion  is  highly  fibrinogenous 
it  is  not  a  matter  of  surprise  that,  under  the  influence 
of  the  globulin-laden  constituents  of  the  blood,  fibrin, 
which  does  not  exude  as  such  from  the  vessels,  should 
be  formed  and  deposited  with  great  readiness.  This 
really  occurs  before  there  is  any  striking  alteration  in 
the  appearance  of  the  membrane,  and  certainly  before 
it  has  lost  its  lustre.  But  even  at  this  early  period  it 
can  be  shown  by  gently  drawing  the  coils  of  intestine 
apart,  when  it  will  be  seen  that  instead  of  gliding 
over  one  another  with  the  usual  facility,  they  stick 
somewhat.  Scraping,  too,  reveals  the  presence  of  a 
small  quantity  of  semi-transparent  glutinous  matter. 
As  the  exudation  becomes  more  profuse  it  collects  in 
the  furrows  formed  by  adjacent  coils  of  bowel.  Here, 
also,  the  hypersemia  is  more  marked  than  elsewhere. 
In  fact,  on  separating  the  coils,  it  will  be  found  that, 
whilst  their  mutual  pressure  had  prevented  the 
accumuldtion  of  blood  in  the  vessels  at  the  surfaces  of 
contact,  it  had  as  a  natural  consequence  increased  the 
tension  in  the  collateral  branches,  and  given  rise  to 
the  so-called  suction-hands  of  congestion  and  exudation 
that  skirt  the  confines  of  the  more  ansemic  parts. 

By  this  time  the  surface  has  lost  its  brightness, 
owing  to  the  loss  of  the  endothelial  layer,  and  the 
coagulation  of  fibrin.  It  looks  minutely  granular  to 
the  naked  eye,  and  with  a  low  magnifying-glass  finely 
reticulate  from  the  interlacing  of  fibrin  filaments. 

Authors  differ  as  to  the  share  that  the  serous 
endothelium  takes  in  the  process.  Those  who  believe 
in  the  formative  quiescence  of  connective-tissue 
corpuscles   generally,    assert  that  here  they   become 


396  Surgical  Pathology.    [Chap. lxxviii. 

loosened  by  the  exudation,  and  softened  by  liquefactive 
degeneration  ;  and  that  the  richly  cellular  neoplasia 
consists  mainly  of  fibrin  and  migratory  leucocytes. 
They  look  upon  the  multi-nucleated  giant-cells  found 
in  the  exudation  as  masses  of  homogeneous  plasma, 
embedding  white  blood-corpuscles. 

Others  state  that  the  endothelial  cells  swell  up, 
and,  together  with  their  nuclei,  divide  and  subdivide, 
and  thus  add  greatly  to  the  vascular  effusion. 

Meanwhile  the  subserous  connective  tissue  becomes 
swollen,  succulent,  and  infiltrated  with  liquor  san- 
guinis and  leucocytes.  Nor  does  the  process  end 
here,  for  the  muscular  coat  of  the  bowel  loses  its 
contractility,  hence  the  tympanites  from  the  un- 
restrained pressure  of  the  gases  within.  It  also 
softens,  as  shown  by  the  readiness  with  which  it  tears 
on  attempting  to  dissociate  adherent  coils  of  bowel. 
In  pelvic  peritonitis  the  bladder  suffers  in  a  similar 
way,  and  is  unable  to  empty  itself  properly. 

So  far  only  the  plastic  stage  of  peritonitis  has 
been  considered,  but  unless  the  inflammation  resolves, 
or  death  of  the  patient  supervenes  at  this  period, 
further  changes  are  observed.  The  exudation 
becomes  more  copious,  and  can  no  longer  be 
retained  upon  the  surface,  and  within  the  meshes 
of  the  membrane.  The  coating  of  lymph,  some- 
times distinctly  laminated,  is  raised  from  its  bed 
by  the  pressure  of  the  fluid  beneath.  It  can  be 
readily  peeled  off,  leaving  a  granular  surface  composed 
of  loops  of  capillary  blood-vessels  surrounded  by 
leucocytes.  The  outward  pressure  of  the  osmotic 
current  separates  the  visceral  and  parietal  layers  and 
the  involutions  of  the  former.  The  fluid  accumulates 
in  the  potential  cavity,  where  it  takes  the  course 
directed  by  gravity  and  least  resistance,  so  it  is  found 
in  greatest  abundance  in  the  pelvis,  flanks,  between 
the  liver  and  the  diaphragm,  and  beneath  the  liver. 


Chap.  Lxxviii.]  Peritonitis.  397 

At  first  it  is  serous,  or  seropurulent  and  cloudy,  and 
generally  contains  some  flakes  of  lymph  washed  off 
from  the  surface  of  the  peritoneum.  Then  it  becomes 
more  turbid,  as  the  number  of  leucocytes  increases, 
and  the  fibrin  in  suspension  augments  in  quantity,  and 
as  both  pass  through  retrograde  granulo-f  atty  changes. 
Finally  it  is  quite  purulent. 

Some  cases  scarcely  go  beyond  a  plastic  exudation, 
some  stop  with  extensive  serous  efi^usion,  whilst  others 
2:)ass  rapidly  into  suppuration.  The  last  is  common 
in  the  asthenic  peritonitis  of  old  and  exhausted 
patients,  where  the  inflammatory  effusion  which  often 
smears  over  the  viscera,  and  resembles  "  melted 
I'jutter,"  is  more  copious  than  one  would  suppose  from 
the  extent  of  the  congestion  observed  post  mortem. 

Acute  purulent  peritonitis  follows  the  admission 
of  highly  irritating  matter,  such  as  would  be  derived 
from  extravasation  of  the  gastro-intestinal  contents, 
rupture  of  an  abscess  containing  very  infective 
(locally)  pus,  or  the  admission  of  air  laden  with 
septic  germs.  Under  the  last-mentioned  conditions 
the  softening  of  the  peritoneum  and  subserous  tissue 
is  so  great,  and  the  vascular  tension  so  high,  that 
capillary  ruptures  are  exceedingly  common  on  the 
surface  of  the  peritoneum,  and  into  the  lymph  which 
covers  it  and  infiltrates  its  substance.  This  is  known 
as  hcemorrhagic  'peritonitis.  The  red  corpuscles  break 
up  very  rapidly,  and  the  liberated  hsemoglobin  decom- 
poses into  other  hesmatin  compounds,  so  that  the 
inflammatory  products  are  variously  stained.  Where 
the  extravasation  is  recent  they  are  deep  red  and 
sanguineous ;  where  it  is  older  they  are  reddish-brown 
and  ochre-coloured. 

The  fluid  contained  in  the  peritoneal  cavity,  which 
is  highly  decomposable,  sometimes  gives  off"  gases  of 
putrefaction.  Inflation  also  happens  when  there  is 
free  communication  with  the   stomach  or  intestines. 


398  Surgical  Pathology.   [Chap.  lxxviii. 

In  either  case  the  tympanitic  note  is  more  uniform 
than  when  the  hyper-resonance  depends  upon  disten- 
tion from  gases  imprisoned  in  the  natural  passages. 

microscopy  of  t!ie  exudation. — The  products 
of  peritonitis  will  be  found  to  vary  as  the  intensity 
and  duration  of  the  inflammation.  In  simple  plastic 
peritonitis  there  will  be  filaments  of  homogeneous 
fibrin,  leucocytes,  and  swollen  endothelial  cells.  In 
purulent  hsemorrhagic  peritonitis  the  fluid  obtained 
from  the  cavity  will  contain  flakes  of  fibrin  in  a  state 
of  granular  degeneration,  pus  cells,  granulo-fatty 
debris,  blood  corpuscles,  pigment  granules,  and  some- 
times crystals  of  hsematoidin,  cholesterine,  and  the 
fatty  acids.  Bodies  of  extra-peritoneal  origin  may 
also  be  discovered,  such  as  the  contents  of  hydatid 
cysts,  and  of  the  gall  bladder,  and  the  intestines. 

Vasciilarisatiou  and  org^anisation ;  adhe- 
sive peritonitis. — As  in  inflammation  of  other 
tissues,  new  blood-vessels  are  formed.  These  are  pro- 
bably derived  for  the  most  part  from  loops  and  buds 
of  pre-existing  vessels ;  but  it  is  quite  possible  that 
some  have  a  separate  origin  in  vaso-formative  cells, 
and  that  they  subsequently  join  the  general  circulation. 

As  the  fluid  is  absorbed,  the  opposite  surfaces 
adhere,  and  the  organisation  into  connective  tissue  is 
the  same  in  every  respect  as  before  described  under 
"  Healing  of  wounds." 

Although  the  peritoneum  is  very  susceptible  to 
the  causes  of  inflammation,  simple  incised  wounds 
heal  very  readily,  provided  the  tension  be  not  too 
great  and  the  injured  surfaces  be  kept  free  from  all 
sources  of  irritation. 

As  plastic  lymph  is  quickly  efiiised,  it  is  the  object 
of  the  surgeon  to  bring  the  cut  edges  of  peritoneum 
closely  together,  so  that  any  communication  with  the 
external  air  or  subjacent  cavities  may  be  shut  off  as 
early  as  possible, 


Chap.  Lxxix.]    Strangulated  Hernfa.  399 

The  young  connective  tissue  undergoes  cicatricial 
contraction,  and  in  this  way  many  of  the  vessels  are 
obliterated.  Band-like  adhesions  become  further 
attenuated,  and  even  broken  through,  by  the  con- 
tinued traction  exerted  upon  them  consequent  on  the 
movement  of  the  parts.  Thus,  the  pedicle  of  an 
ovarian  tumour  fixed  in  an  operation  wound  may  in 
course  of  time  atrophy  and  lose  its  connection  with 
the  abdominal  wall. 


CHAPTER   LXXIX. 

STRANGULATED    HERNIA. 

The  symptoms  of  strangulated  hernia  are  depen- 
dent more  upon  the  nipping  of  the  nerves  and  acute 
congestion  ot'  the  vessels  than  upon  obstruction  of  the 
bowel ;  for  in  some  cases  of  obturator  and  femoral 
hernia,  where  only  a  part  of  the  calibre  of  the  gut  is 
involved,  and  where  there  is  consequently  but  partial 
oljstruction,  the  local  pain  and  the  vomiting  may  be 
just  as  pronounced  as  when  several  coils  are  tightly 
constricted.  The  irritation  of  the  visceral  nerves  is 
reflected  through  the  abdominal  "sympathetic"  system, 
and  shows  itself  as  widely-distributed  pain,  reverted 
peristaltis,  and  increased  secretion  of  the  mucous 
glands. 

Brinton  explained  the  stercoraceous  vomiting  by 
direct  onward  contraction  of  the  alimentary  canal, 
and  not  by  its  reversal.  According  to  this  view,  a 
circumferential  current  is  established,  which,  on 
meeting  with  obstruction  at  the  seat  of  strangulation, 
is  turned  back  in  the  long  axis  of  the  bowel.  This 
would  be  possible  so  long  as  the  propelling  tube 
remained    full,    but    could    not   take    place   when   it 


400  Surgical  Pathology,      ichap.  lxxix. 

became  practically  collapsed  and  empty.  Moreover, 
experiments  on  the  lower  animals  show  that  acute 
constriction  is  followed  by  reversed  peristaltis  ;  and  no 
doubt  this  is  what  obtains  in  strangulated  hernia. 

Mediaoism  of  i^tr angulation. — When  the 
neck  of  the  sac  is  narrow  and  inexpansile,  and  the 
surrounding  structures  are  rigid,  strangulation  is 
effected  immediately  after  the  descent  of  the  bowel ; 
hence  this  is  likely  to  happen  in  recent  hernise,  and  in 
old  ones  that  have  been  kept  habitually  reduced  by  a 
truss.  On  the  other  hand,  where  the  neck  of  the  sac 
is  wide,  unless  several  coils  of  intestine,  or  a  single 
knuckle  and  a  piece  of  omentum,  are  forcibly  driven 
through  the  orifice,  the  symptoms  are  developed  more 
slowly  as  the  veins  and  capillaries  become  gorged 
with  blood.  As  in  constriction  of  a  limb,  the  current 
through  the  veins  is  arrested  before  that  in  the 
arteries. 

Subsequent  serous  effusion  into  the  sac  increases 
the  tension ;  for,  although  fluid  pressure  is  equal  in 
all  directions,  it  tells  most  on  the  least  resilient  parts, 
i.e..,  at  the  neck  of  the  sac  and  aperture  of  exit  in  the 
abdominal  walls. 

State  of  the  bowel. — In  the  first  instance 
there  is  intense  venous  congestion,  which  causes  the 
protruded  gut  to  present  a  dark  red  appearance. 
Then,  if  the  tension  be  not  relieved,  it  sets  up  inflam- 
mation. The  effusion  changes  its  character  from 
serous  to  plastic,  and  the  peritoneal  coat  loses  its 
lustre  from  desquamation  of  the  endothelial  covering 
and  coagulation  of  lymph  on  the  surface.  Mean- 
while the  walls  of  the  gut  are  much  thickened  by 
congestion  and  exudation,  and  at  the  same  time  they 
are  softened. 

As  the  strangulation  continues,  stasis  is  followed 
by  coagulation,  and  the  parts  cut  off  completely  from 
their  vascular  supply  lose  their  vitality  and  become 


Chap.  Lxxix.]    Strangulated  Hernia.  401 

gangrenous.  AVlien  this  stage  is  reached  the  bowel  is 
black.  Later  on  the  blood  corpuscles  are  broken  up, 
and  the  colouring  matter  is  discharged,  and  then 
there  are  dirty  slate-grey  patches.  The  condition  is, 
in  factj  typical  of  moist  gangrene,  and  the  tissues  are 
so  rotten  that  very  little  violence  is  necessary  to 
break  them  down  j  hence  the  danger  of  forcible 
attempts  at  taxis.  Rupture  of  the  gut  may  take 
place  into  the  sac  or  the  abdominal  cavity.  In 
the  latter  case  it  gives  way  on  the  proximal  side  of 
the  constricted  coil;  for,  in  addition  to  the  uniform 
compression  at  the  neck,  there  is  the  mechanical  dis- 
tiu'bance  from  peristalsis,  w^hereas  the  bowel  on  the 
distal  side  of  the  strangulation,  after  emptying  itself 
of  its  contents,  remains  collapsed  and  comparatively 
quiescent. 

The  effect  of  distention  and  softening  of  the  walls 
of  the  capillaries  is  occasionally  seen  in  the  form  of 
hcemorrhage  into  the  hoicel  after  reduction  of  the 
hernia.  Such  an  event  at  first  suggests  ulceration 
into  a  large  vessel,  for  the  bleeding  may  be  very 
copious  (I  have  knoAvn  half-a-pint  of  blood  passed  per 
I'ectum)  j  but  this  is  not  the  case.  The  capillaries  of 
the  mucous  membrane,  ha^ving  lost  their  natural 
j)Ower  of  resistance,-  burst  under  the  force  of  the 
ai-terial  cuiTent  let  in  upon  them  after  the  strangula- 
tion has  been  rehevecl.  Extravasation  to  any  great 
extent  is  very  rare,  whereas  mucous  and  submucous 
ecchymoses  are  common  enough. 

Fluid  contents  of  the  sac. — In  all  cases  of 
strangulated  hernia  there  is  a  certain  amount  of 
serous  exudation  from  the  congested  vessels  of  the 
bowel,  or  omentum,  or  whatever  else  may  compose 
the  hernia.  Where  the  sac  is  large,  and  the  rupture 
small,  the  fluid  accumulation  may  be  very  extensive. 
The  nature  of  the  exudation  varies  with  the  degree 
and  duration  of  strangulation  :  thus,  it  is  clear  and 

A  A 


402  Surgical  Pathology.      [Chap,  lxxix. 

straw-coloured  ;  or  pink,  or  deep  red,  from  admixture 
with  blood,  and  dissolved  haemoglobin ;  or  turbid  from 
pus  and  flakes  of  lymph,  the  result  of  peritonitis  ;  and 
lastly,  it  is  sometimes  mixed  with  the  contents  of 
ruptured  gangrenous  bowel,  or  the  gaseous  products 
of  decomposition. 

Apart  from  strangulation,  the  sac  of  a  hernia  may 
be  dropsical  and  distended  with  clear  serous  fluid, 
when  it  simulates  funicular  or  congenital  hydrocele. 
This  condition  is  known  as  "hydrocele  of  the  hernial 
sac." 

Artificial  anus  is  an  unnatural  opening  of  the 
bowel  on  the  surface  of  the  body.  It  is  made 
intentionally  in  the  operation  of  colotomy.  If  a 
patient  survive  the  occurrence  of  gangrene  of  the 
bowel  from  strangulated  hernia,  the  peritoneal  sac  is 
laid  open  by  incision,  or  by  a  com.bined  process  of 
sloughing  and  ulceration.  On  cutting  into  the  gut,  if 
it  has  not  already  ruptured,  the  contents  escape,  and 
a  communication  is  established  with  the  lumen  of  the 
intestine  on  each  side  of  the  seat  of  strangulation. 
Extravasation  into  the  general  peritoneal  space  is 
prevented  by  previous  plastic  adhesion  between  the 
visceral  and  parietal  layers  of  the  peritoneum.  The 
pressure  of  the  underlying  abdominal  viscera,  together 
with  the  peristaltic  action  of  the  bowel  on  the 
proximal  side  of  the  artificial  anus,  forces  down  the 
partition  formed  by  the  adherent  walls  of  the  proximal 
and  distal  segments  of  the  gut.  The  outward  flow  of 
intestinal  contents  from  the  proximal  segment  keeps 
its  orifice  dilated,  whilst  the  pressure  exerted  by  the 
escape  of  fseculent  matter,  coupled  with  the  projection 
of  the  partition  above  referred  to  (Dupuytren's  spur), 
causes  the  opening  of  the  lower  collapsed  portion  of 
bowel  to  remain  practically  closed.  The  treatment  of 
artificial  anus  consists  essentially  in  getting  rid  of  the 
spur-like  barrier. 


403 


CHAPTER  LXXX. 

IXTUSSUSCEPTION    OF    THE    BOWEL. 

When  one  portion  of  intestine  is  invaginated  in 
another  the  condition  is  known  as  intassusce^otion.  It 
is  by  no  means  rare  to  find  one  or  more  such  involu- 
tions post  mortem,  in  cases  where  no  symptoms  pointed 
to  their  existence  during  life.  It  is  doubtful  whether 
they  are  formed  before  or  after  death,  for  peristalsis  can 
be  excited  in  animals  by  direct  or  indirect  stimulation 
for  some  time  after  the  heart  has  ceased  to  beat. 
Tliese  so-called  "  post-mortem  invaginations  "  can  be 
reduced  quite  easily.  For  their  development  there 
must  be  an  irregular  contraction  of  different  portions 
of  the  bowel.  Thus,  if  one  segment  is  in  a  state  of 
peristalsis  whilst  that  immediately  succeeding  it 
remains  relaxed,  the  former  can  readily  glide  into  the 
latter.  The  sudden  increase  in  the  calibre  of  the 
intestine  beyond  the  ileo-csecal  orifice  is  the  chief 
reason  why  intussusception  is  more  common  in  this 
situation  than  elsewhere. 

Children  are  more  liable  to  it  than  adults  :  (1) 
l)ecause  in  them  the  general  reflex  excitability  is  very 
marked,  and  the  bowel  is  readily  excited  to  irregular 
peristaltic  action  through  irritation  of  its  nerves  by 
ascarides,  or  other  oflfending  matter;  (2)  on  account  of 
the  disposition  of  the  peritoneum.  It  should  be 
remembered  that  the  part  first  invaginated  always 
remains  the  lowest,  or  in  other  words,  that  the 
ensheathed  portion  merely  travels  on,  whilst  the 
ensheathing  tube  is  being  continually  rolled  in ;  so 
that  if  the  invagination  commences  at  the  ileo-csecal 
valve,  this  will   be  found   the    most   advanced  part. 


404  Surgical  Pa  thology.       [Chap.  lxxx. 

Now,  in  children  the  csecum  is  freely  swung  by  the 
mesentery,  instead  of  being  fixed  in  the  iliac  fossa,  as 
it  is  in  the  adult,  and  consequently  there  is  less  check 
upon  its  involution. 

The  ensheathed  portion  of  bowel  acts  as  a  foreign 
body,  and  stimulates  the  surrounding  muscular  walls 
to  continued  contraction.  This  may  not  cease  until 
the  ileo-csecal  valve  has  reached  the  rectum,  or  even 
protruded  from  the  anus.  The  attachment  of  the 
peritoneum  hinders  the  descent  of  the  bowel  chiefly  at 
its  posterior  aspect,  so  that  the  orifice  of  the  invaginated 
tube  looks  somewhat  backwards.  This  should  be 
borne  in  mind  on  rectal  examination,  as  otherwise  the 
prolapse  might  be  mistaken  for  a  polypus,  from 
which,  however,  it  otherwise  differs  in  not  being  fixed 
at  one  spot. 

The  symptoms  are  dependent  on  the  degree  of 
strangulation,  and  not  on  the  simple  existence  of 
invagination,  just  the  same  as  in  an  ordinary  external 
hernia. 

Chaug^es  secoaidary  to  strang^ulation. — 
The  blood-vessels  of  the  prolapsed  gut  become 
engorged,  then  inflammation  sets  in,  and  the  part 
is  much  swollen.  The  mucous  membrane  secretes  a 
quantity  of  thick  mucus,  which,  together  with  some 
blood  derived  from  rupture  of  capillaries,  is  often 
discharged  from  the  anus.  Lymph  is  thrown  out  on 
the  opposed  peritoneal  surfaces,  which  it  glues 
together  after  the  process  of  invagination  is  complete. 
As  the  result  of  acute  strangulation  the  ensheathed 
bowel  may  slough  away.  Extravasation  of  intestinal 
contents  into  the  peritoneal  cavity  is  prevented  by 
plastic  exudation  uniting  the  contained  and  containing 
portions  of  bowel  at  the  base  of  the  invagination. 
But  before  the  gangrenous  part  has  time  to  separate 
the  patient  usually  dies  from  collapse  or  general 
peritonitis ;    and   where  it   is    effected    there    is   the 


Chap.  Lxxxi.]  Tumours.  405 

certainty  of    an  annular   stricture  from  cicatrisation 
of  the  inflammatory  products. 


CHAPTER    LXXXI. 

TUMOURS. 

"  A  TUMOUR  is  a  mass  of  new  formation  that  tends 
to  gi'ow  and  persist."  This  tendency  is  in  marked 
contrast  to  that  of  inflammatory  neoplasias,  which  is 
to  arrive  at  a  typical  termination.  Fatty  tumours, 
it  is  true,  frequently  become  arrested  in  their  growth, 
and  papillomata,  as  in  the  case  of  common  warts, 
often  disappear  spontaneously  \  but  still  the  tendency 
is  the  other  way.  Again,  although  long- continued 
irritation  may  certainly  be  the  exciting  cause  of  a 
tumour,  as  in  the  case  of  epithelioma  of  the  lip  and 
tongue  from  friction  against  a  pipe  or  tooth,  and  in 
the  same  disease  sometimes  starting  at  the  seat  of  old 
chronic  inflammatory  lesions,  such  as  syphilitic 
ulceration  of  the  tongue  and  skin,  yet,  whilst  we  can 
produce  inflammation  at  will,  we  have  no  absolute 
power  of  producing  a  tumour  at  all. 

In  studying  the  anatomical  basis  of  tumours,  it 
will  be  found  that  they  all  have  their  "  type  in  some 
natural  tissue  of  the  body,  either  in  the  embryonic  or 
developed  state."  In  other  words,  a  tumour  is  not  a 
parasite ;  there  is  nothing  truly  alien  in  its  nature ; 
it  is  the  rebellious  scion  of  a  parent  stock.  If  the 
elements  of  a  new  growth  are  like  those  of  the  tissue 
where  they  are  found,  they  are  said  to  be  liomoflastic, 
e.g.,  osteoma  growing  from  bone ;  if  they  diJQfer,  they 
are  termed  heteroplastic,  e.g.,  enchondroma  of  the 
testicle.     From    a   knowledge    of   the    fact  that  any 


4o6  Surgical  Pathology.      [Chap,  lxxxi. 

anatomical  or  physiological  peculiarity  of  a  tissue  is 
usually  stamped  upon  the  tumour  springing  from  it, 
a  great  insight  as  to  the  probable  nature  of  the  latter, 
may  be  obtained ;  thus  one  would  expect  osteoma, 
enchondroma,  and  sarcoma  to  be  frequently  connected 
with  bone,  myo-libroma  with  the  uterus,  and  so  on. 
Why  also  myeloid  sarcoma  should  have  its  seat  almost 
exclusively  in  bone,  and  why  sarcoma  of  the  choroid 
should  be  melanotic,  and  giio-sarcoma  of  the  retina 
and  nerve  centres  present  a  stroma,  like  that  of 
the  natural  structure  of  these  parts. 

A  tumour  is  malignant  in  proportion  to  the  rate 
at  which  it  destroys  the  tissue  and  tends  to  shorten 
life. 

It  is  impossible  to  denote  definitely  where  malig- 
nancy ends  and  benignancy  begins,  for  not  only  are 
there  forms  of  intermediate  gravity,  but  in  the  history 
of  a  given  growth  it  may  so  alter  in  character  as 
scarcely  to  be  described  by  the  same  name;  e.g.^  a 
"  recurrent  fibroid "  may  at  first  consist  largely  of 
fibrous  tissue,  but  each  successive  recurrence  after 
operation  is  often  marked  by  a  great  increase  in  the 
number  of  cells. 

The  signs  of  isialigiiaucy  are  : 

(1)  Local  recurrence  after  apparently  complete 
removal. 

(2)  Dissemination  or  generalisation  in  other  parts, 
either  directly  by  associated  lymphatics,  or  more 
i-emotely  by  the  blood-vessels.  Multiplicity  of  growth 
may  in  some  cases  be  explained  as  a  general  outbreak 
from  a  common  source,  rather  than  a  causative 
sequence.  It  is  intei-esting  to  note  that  the  secondary 
growths  usually  maintain  the  type  of  the  primary  ; 
thus  alveolar  cancer  of  the  breast  is  reproduced 
in  the  lymphatic  glands,  liver,  and  other  parts; 
columnar  epithelioma  of  the  rectum,  in  the  liver ; 
squamous    ejDithelioma    of    the    lip,    in   the    cervical 


Chap.  LXXXL]      CLASSIFICATION  OF    TUMOURS.  407 

lymphatics ;  melanotic  sarcoma  of  the  skin  and  colloid 
cancer  of  the  omentum  or  ovary  follow  the  same 
rule. 

(3)  Infiltration  of  surrounding  tissues  by  the  ele- 
ments of  the  tumour. 

(4)  Rapidity  of  increase,  leading  to  destruction  by 
ulceration  or  sloughing.  The  vital  activity  of  the 
cells  being  expended  more  in  multiplication  than  in 
development,  leads  to  a  deficient  vascular  supply,  and 
great  liability  to  sufier  from  injury. 

(5)  Multiplicity,  though  suggestive  of  malignancy, 
does  not  necessarily  imply  it,  for  some  benign  new 
formations  (e.^.,  fatty  tumours  and  atheromatous 
cysts)  are  often  multiple. 

(6)  An  apyrexial  cachexia  from  impaired  assimi- 
lation leading  to  general  wasting. 

(7)  The  influence  of  heredity  is  certainly  more 
marked  in  maligTiant  than  in  simple  tumours. 

(8)  Direction  of  growth.  Benign  tumours  spring- 
ing from  a  surface  are  centrifugal ;  malignant,  both 
centrifugal  and  centripetaL  Compare  the  mere  out- 
growth of  a  papilloma  with  the  deeply-rooted  invasion 
of  an  epithelioma. 

Classification  of  tiimours. — Formerly,  when 
tumours  Avere  arranged  on  a  clinical  basis^  such  terms 
as  "  medulloma,"  "  encephaioma,"  "soft  cancer,"  etc., 
were  applied  without  distinction  to  any  soft,  rapidly- 
growing  new  formation.  In  like  manner,  the  word 
"  melanoma  "  was  used  to  indicate  a  tumour  contain- 
ing pigment.  It  is  true  the  other  attributes  were 
implied,  but  it  was  none  the  less  unscientific,  for  a  soft 
wart  on  the  skin  may  be  as  black  as  a  virulent  melanotic 
cancer  or  sarcoma.  We  now  employ  an  anatomical 
classification,  for  it  serves  to  point  out  the  re- 
semblances and  differences  of  allied  growths,  and  to 
distinguish  between  their  essential  nature  and  their 
suboidinate  nutritive  modifications.      Relying   upon 


4o8  Surgical  Pathology,    [Chap,  lxxxti. 

tlie  microscope,  there  is  no  fear  of  mistaking  a  dis- 
integrating infarct  for  a  malignant  tumour. 


CHAPTER    LXXXIL 

THE    FIBEOMATA. 

"VYhite  fibrous  tissue  exists  in  abundance  in  many 
tumours.  In  some,  e.g.,  the  fibro- adenomata,  the 
fibrous  element  far  outstrips  the  glandular.  But  the 
term  fibroma  denotes  the  absence  from  the  growth 
of  any  more  characteristic  structural  constituent. 

The  fibromata  rank  amongst  the  benign  tumours. 
They  arise  from  connective  tissue,  especially  the  sub- 
cutaneous and  submucous,  but  they  are  met  with  in 
many  other  parts.  The  so-called  "  fibroid  "  tumours 
of  the  uterus  belong  more  strictly  to  the  myomata, 
with  which  they  will  be  considered.  We  shall  divide 
the  fibromata  into  three  groups :  (1)  The  isolated 
encapsuled  tumours  situated  beneath  the  surface ; 
(2)  the  more  widespread  overgrowths  of  the  cutaneous 
and  subcutaneous  connective  tissue,  known  as  hyper- 
trophies or  diffuse  fibromata  ;  (3)  fibrous  polypi.  It 
may  be  stated  generally  that  when  fibrous  tumours 
commence  either  in  the  skin  or  immediately  beneath 
it,  or  in  the  submucous  tissue,  the  tendency  is  for 
them  to  become  pedunculated. 

The  fibromata  naturally  fall  under  two  heads,  ac- 
cording to  their  consistence  and  vascularity.  Thus 
we  speak  of  the  firm  and  soft  varieties. 

In  structure  the  fibromata  present  the  same 
variations  of  textural  arrangement  as  attains  in  normal 
white  fibrous  connective  tissue.  The  greater  portion 
of  the  tumour  consists  of  bundles  of  fibres  interwoven 


Chap.  Lxxxii.]  The  Fibromata.  409 

ill  various  directions.  The  general  disposition  of 
these  bundles  is  along  the  course  of  the  blood-vessels ; 
very  often  thej  form  concentric  layers  around  the 
latter,  giving  the  section  a  lobulated  appearance, 
and  this  is  more  marked  when  the  bundles  between 
the  lobules  are  less  closely  packed  than  those  which 
constitute  the  latter.  In  some  cases  the  fibres  are 
loosely  interlaced,  forming  an  open  mesh-work ; 
in  others  they  are  so  intimately  connected  as  to 
partially  obscure  the  fibrillation.  The  fibrillation 
itself  varies  much,  so  that  microscopical  sections 
appear  like  spun  glass,  or  present  wavy  fibres  with 
definite  outline.  Elastic  tissue  is  usually  absent. 
The  cells  show  great  diversity  in  number,  size,  and 
shape  in  different  tumours,-  and  in  different  parts  of 
the  same  tumour.  The  younger,  too,  the  tissue,  the 
larger  and  more  numerous  the  cells  ;  in  fact,  it  may 
be  difficult  in  the  earliest  staQ-es  to  distino-uish 
between  a  developing  fibroma,  myoma,  and  spindle- 
celled  sarcoma.  For  the  most  part,  however,  the  cells 
are  small.  They  are  round,  angular,  fusiform,  or 
branched.  Some  elongate,  and  become  finally  lost 
amongst  the  fibres  with  which  they  blend.  We  have 
examined  specimens  where  not  a  single  cell  could  be 
seen.  On  the  whole,  the  fibromata  are  scantily 
supplied  with  blood-vessels ;  some  appear  almost 
devoid  of  them.  The  softer  forms  are  more  vascular, 
and  are  sometimes  permeated  by  a  cavernous  network. 

Secondary  cliang-es. — The  most  constant  is 
calcification,  either  confined  to  the  septa  or  as  a 
petrifaction  of  the  entire  tumour.  ISText  to  this  comes 
mucoid  softening.  True  cystic  formation  is  rare. 
The  skin  may  ulcerate  over  them,  and  the  inflamma- 
tion spread  into  the  interior,  but  they  are  not  subject 
to  primaiy  suppuration. 

The  firm  fibromata  are  very  dense,  creaking  on 
being  cut  with  a  knife.     The  cut  surface  looks  dead- 


41  o  Surgical  Pathology.    [Chap,  lxxxii. 

white  and  coarsely  fasciculated,  or  greyish  and  glis- 
tening, according  to  the  degree  of  homogeneity  of 
structure. 

They  grow  from  fasciae,  bone,  periosteum,  nerves, 
and  other  parts.  Well  -  marked  examples  are  the 
fibrous  e'pulides  of  the  jaws,  which  spring  from 
the  bone  or  periodontal  membrane,  not  from  the 
mucous  membrane  of  the  gums.  They  project  by  the 
side  ,of  the  teeth,  which  frequently  become  loose. 
When  they  ossify  (and  this  is  not  rare),  the  bone  is 
deposited  in  the  direction  of  the  vessels,  i.e.,  from  the 
point  of  attachment  toAvards  the  periphery.  If 
completely  removed  there  is  almost  entire  immunity 
from  recurrence.  Ossification  may  advance  to  within 
a  short  distance  of  the  surface,  which  is  covered  by 
mucous  membrane. 

What  are  known  clinically  as  neuromata  consist 
either  of  mucous,  or  of  firm  fibrous  tissue.  {Vide 
Myxoma.)  The  fibrous  neuromata,  like  the  mucous, 
start  from  the  connective  tissue  around  the  nerves  and 
between  the  fasciculi.  The  nerve-fibres  are  stretched 
over  the  tumour.  We  have  seen  a  fibrous  neuroma 
the  size  of  an  egg.  Under  the  microscope  it  showed 
minute  cells  distributed  with  great  regularity  through 
a  delicately  fibrillated  stroma.  Some  nasal  polypi 
belong  to  the  firm  fibromata. 

The  soft  fitoroMiata  include  the  diffuse  fibrous 
hypertrophies  of  the  subcutaneous  tissue,  and  many 
pedunculated  tumours  attached  to  the  skin  and  mucous 
membranes.  The  diffuse  fibromata  consist  of  loosely 
woven  bundles  of  connective  tissue,  in  the  interstices 
of  which  the  vessels  ramify;  the  latter  are  sometimes 
very  large.  They  form  doughy  masses,  which  some- 
times hang  in  overlapping  folds  from  the  buttocks, 
thighs,  and  other  parts  of  the  body.  From  its  struc- 
ture and  consistence  the  new  formation  was  called 
molluscum  fi)rosum,  or  fibroma   molluscum,  a  name 


Chap.  Lxxxii.]         Fibrous  Polypi.  411 

still  in  use,  but  now  generally  restricted  to  the  fleshy 
librous  polypi  of  the  skin. 

When  the  subcutaneous  soft  fibromata  project 
from  the  skin  as  sessile  or  broadly  pedunculated 
masses  they  are  known  as  wens.  Like  the  other 
diifuse  fibromata,  they  have  no  capsule. 

Elephantiasis  Arabum  bears  a  marked  structural 
resemblance  to  diffuse  fibroma,  but  instead  of  being  a 
simple  non-inflammatory  overgrowth,  it  appears  to 
be  closely  connected  with,  if  not  dependent  upon, 
recurrent  attacks  of  lymphangitis.  The  scrotum  and 
legs  are  the  parts  usually  afiected.  The  growth  often 
assumes  enormous  dimensions,  weighing  as  much 
as  forty  or  fifty  pounds.  It  is  mostly  found  in 
Orientals. 

Circumscribed,  encapsuled,  soft  fibromata  are  met 
with  in  the  subcutaneous  tissue,  but  they  are  much 
rarer  than  the  difluse  variety. 

Fibrous  polypi  occur  on  the  cutaneous  and 
mucous  surfaces.  They  may  be  considered  as  localised 
overgrowths  of  the  subcutaneous  and  submucous 
tissues.  Those  growing  from  the  skin  have  been 
referred  to  under  the  name  "molluscum  fibrosum." 
They  are  usually  multiple.  Their  number  may  in 
some  cases  be  counted  by  tens  and  hundreds.  In 
size  they  vary  from  a  pea  to  a  potato.  T.  Fox 
describes  two  forms,  the  simple  and  the  fungoid ;  the 
latter  are  very  vascular,  and  liable  to  ulcerate  and 
fungate. 

Soft  fibrous  polypi  of  the  mucous  membranes  are 
met  with  in  the  uterus,  vagina,  stomach,  and  intestines ; 
but  those  of  greatest  surgical  interest  grow  from  the 
naso2:)harynx  and  contiguous  sinuses — frontal,  sphe- 
noidal, etc.  Clinically,  many  of  them  are  more  nearly 
related  to  the  sarcomata  than  to  the  fibromata,  for 
they  tend  to  continuous  growth,  absorb  everything  in 
their   way,    and  often   recur   after  removal.     Others, 


412  Surgical  Pathology.   [Chap,  lxxxiii. 

however,    are    quite    innocent    in   their    nature,    and 
between  them  there  is  every  gradation. 

They  contain  a  good  deal  of  mucous  tissue,  and 
are  more  vascular  and  succulent  than  those  attached 
to  the  skin. 


CHAPTER  LXXXIII. 

THE    LIPOMATA. 

The  majority  of  fatty  tumours  are  met  with 
between  the  ages  of  thirty  and  fifty,  when  there  is  a 
general  disposition  to  obesity.  The  local  determination 
of  the  growth  can  in  many  cases  be  referred  to  some 
injury  or  long-continued  friction.  They  are  occa- 
sionally hereditary.  They  are  situated  chiefly  on  the 
trunk,  especially  about  the  shoulders  and  waist ;  parts 
subject  to  the  pressure  of  articles  of  dress,  such  as  the 
braces,  corset,  etc.  ;  here  they  spring  from  the  sub- 
cutaneous fatty  tissue.  Local  collections  of  fat  are 
seen  now  and  again  in  the  synovial  fringes  of  joints 
and  tendon  sheaths,  resembling  the  appendices  epi- 
ploicse  of  the  omentum.  Fatty  tumours  mostly  occur 
singly,  but  several  may  be  found  in  the  same  subject, 
the  more  so  when  hereditary. 

Cceneral  anatomy.— As  a  rule  they  form 
roundish  projections  on  the  surface  of  the  body.  The 
most  constant  feature  is  a  lobulation ;  this  may  be 
visible,  or  be  made  out  only  on  manipulation,  or  after 
dissection.  When  pressure  is  made  on  the  skin  at  the 
margin  of  the  tumour,  that  over  the  surface  becomes 
dimpled,  from  stretching  of  the  interlobular  bundles 
of  fibrous  tissue  that  are  fixed  to  the  under  surface  of 
the  skin. 

The   author  has    seen    a  polypus   as  large   as   an 


Chap.  Lxxxiii.]  The  LiPOMATA.  413 

orange  attached  by  a  narrow  stalk  to  the  buttock ;  one 
half  of  the  structure  was  composed  of  fat  intermingled 
with  the  other,  which  consisted  of  dense  fibrous  tissue 
(fibrous  lipoma). 

The  lipomata  are  usually  circumscribed  and  limited 
by  a  distinct  capsule,  which  is  fixed  to  the  surrounding 
tissue  by  a  loose  meshwork  and  strong  bands  of 
fibrous  tissue.  The  latter  conduct  the  blood-vessels, 
which  enter  chiefly  at  the  upper  and  deeper  parts. 
The  external  attachment  may  be  so  slight  that  the 
tumour  changes  its  position;  the  resistance  met  with 
in  the  subcutaneous  cellular  tissue  being  slight,  the 
force  of  gravity  is  sufficient  to  cause  the  displacement. 
In  such  cases  the  fibro-vascular  bands  become  stretched. 

Very  rarely  fatty  tumours  show  no  limitation,  the 
fat  composing  them  being  continuous  with  the  normal 
tissue  around  (difiuse  lipoma).  They  have  occasion- 
ally been  found  connected  with  the  peritoneum,  by  a 
prolongation  of  the  latter  through  a  cleft  in  the 
abdominal  wall,  particularly  at  the  linea  alba ;  they 
then  grow  from  the  retroperitoneal  fat.  The  possible 
danger  attending  their  removal  is  obvious. 

Fatty  tiunours  vary  in  consistence.  They  may  be 
so  soft  and  elastic  as  to  simulate  fluid  collections; 
chronic  abscesses  and  sebaceous  cysts  have  been  mis- 
taken for  them.  On  the  other  hand,  they  may  be  very 
firm,  resembling  fibrous  tumours.  The  lobules  are  sepa- 
rated by  areolar  tissue,  in  which  the  supplying  vessels 
are  embedded.  The  amount  of  this,  together  with 
the  composition  of  the  fat  in  a  given  case,  explains  the 
density.  In  colour  they  are  bright  yellow,  or  yellowish 
white.  In  children,  especially,  they  often  contain  a 
considerable  quantity  of  erectile  tissue,  so  that  by 
pressure  their  size  can  be  much  diminished ;  and  they 
bleed  freely  on  removal  (nsevoid  lipoma). 

Compare  a  fatty  tumour  after  enucleation  with 
an  enchondroma  of   a   long  bone   or  the  peMs,  and 


414 


Surgical  Pathology,   [dap.  lxxxiii. 


an  agglomeration  of  enlarged  lymphatic  glands  in 
Hodgkin's  disease.  All  these  are  lobulated,  but  the 
enchondroma  is  very  hard,  of  a  bluish -white  colour, 
and  is  attached  to  bone.  The  glands  are  not  so 
yellow  as  fatty  tumour,  but  they  are  firmer,  and  large 
trunk  vessels  can  usually  be  seen  passing  through  the 
mass,  for  it  is  usually  taken  from  the  abdominal 
mediastinal  or  cervical  regions. 

Lipoma  forms  compound  tumours  with  myxoma, 
sarcoma,  and  fibroma. 

Microscopy. — The  greater  part  consists  of  fat  cells, 
which  do  not  differ  from  the  normal,  except  that  they 


Fig.  60.— Fatty  Tiunour. 

The  cells  a,  exactly  in  focus,  have  a  more  strongly  marked  outline  than  those,  b, 
immediately  beneath  them :  c,  blood-^vessel ;  connective-tissue  corpuscles 
lie  between  the  fat  cells,    x  265. 

are  somewhat  larger.  They  are  roundish  or  polygonal 
from  mutual  pressure.  The  cells  just  out  of  focus  are 
seen  in  dim  outline  (Fig.  60).  Bundles  of  areolar  tissue 
and  blood-vessels  run  between  the  lobules.  Fine  fibres 
and  connective  tissue  cells  may  be  found  between  the 
individual  fat  cells.  This  last  phenomenon  is  explained 
by  the  mode  of  growth,  for  the  cells  do  not  contain  fat 
at  first;  this  is  stored  up  later.  The  first  cells  of  the 
tumour  are  derived  from  the  connective  tissue,  and  the 
tumour  increases  in  size  by  the  addition  of  new  cells 


Cnap.  LXXXIV.]      ThE   EnCHONDROMATA.  415 

produced  by  vaciiolation  and  division  of  pre-existing 
ones,  and  probably  also  by  the  fixation  of  wandering 
cells.  The  interlobular_,  and,  to  some  extent,  the 
intralobular,  tissue  is  filirillated. 

Secondary  cbaug^es. — Fatty  tumours  are  not 
very  prone  to  structural  modifications. 

Calcification  and  even  ossification  are  occasionally 
met  vrith  in  the  matrix.  The  fat  may  alter  its  com- 
position and  become  semifluid.  The  fatty  acids  may 
then  be  set  free  and  crystallise ;  this  is  often  produced 
by  the  action  of  reagents  used  in  the  preparation  of 
microscopical  sections.  The  skin  over  them  may  be 
atrophied  by  the  continuous  pressure,  and  this,  together 
with  accidental  injury,  may  cause  ulceration  of  the 
mass.     Central  suppuration  rarely  or  never  occurs. 

Fatty  tumours  neither  generalise  nor  recur  locally 
after  removaL 


CHAPTER   LXXXIY. 

THE    ENCHONDROMATA, 

These  tumours,  which  have  their  type  in  cartilage, 
grow  for  the  most  part  from  bone,  and  that  too  in  the 
^^.cinity  of  diarthrodial  joints  and  synchondroses. 

They  are  not,  however,  confined  to  these  situations, 
but  are  found  in  tissues  {e.g.^  the  parotid  gland  and 
testicle),  in  which  at  no  period  of  their  natural  existence 
is  any  trace  of  cartilage  to  be  seen.  They  never 
sjmng  from  cartilage.  It  must  be  borne  in  mind  that 
cartilage  is  a  primary  derivative  of  embryonic  tissue, 
and  hence  it  is  not  surprising  that  it  should  be 
developed  where  the  latter  forms  the  structural  basis 
of  new  growths. 

The   admixture  of  cartilage  with  embryonic  and 


4i6 


Surgical  Pathology.    [Chap.  lxxxiv. 


mucous    tissue    is  thus  readily  explained,  and   hence 
the  varieties,  chondro-sarcoma,  chondro-myxoma,  etc. 

Most  enchondromata  are  innocent  in  their  nature, 
rarely  giving  rise  to  secondary  deposits.  When  these 
occur  it  is  chiefly  in  the  lungs.  If  all  the  indifferent 
cells  are  used  up  in  the  production  of  cartilage,  the 
tumour  may  fairly  be  designated  an  enchondroma ;  but 
where  there  is  only  a  limited  conversion,  it  is  better  to 


—  a 


Fig.  61. — Myxo-Cliondroma  of  Parotid  Gland. 

a,  Hyaline  cartilage ;  6,  nlucous  tissue,  -rtith  stellate  corpuscles  atid  slightly 
flbrillated  gelatinous  matrix ;  c,  cartilage  capsule,  containing  a  nucleated  cell 
and  a  fat  globule,    x  265. 

speak  of  it  as  a  chondrification,  for  the  specific  nature 
of  the  growth  is  not  modified  thereby.  A  sarcoma  is 
none  the  less  malignant  because  islets  of  cartilage  are 
scattered  through  its  substance.  We  have  seen  this 
in  a  testicle  removed  during  life  (Fig.  53).  The  patient 
died  within  six  months,  with  secondary  deposits  in  the 
lumbar  and  mediastinal  glands,  and  nearly  all  the 
abdominal  viscera.     In  another  case  the  association  of 


Chap.  Lxxxiv.]   The  Eaxhondromata.  417 

sarcoma  with  enclioudroma  was  delayed ;  but  what 
appeared  at  first  to  be  an  innocent  tumour  of  the 
parotid  (for  it  only  attained  the  size  of  a  small  orange 
in  twelve  years),  subsequently  made  such  progress 
that  it  doubled  its  size  in  six  months ;  one  half  was 
composed  of  hyaline  chondro-myxoma  {vide  Fig.  61), 
the  other  of  large  round-celled  sarcoma. 

It  may  be  said,  then,  that  cartilaginous  tumours  of 
parenchymatous  organs  should  always  be  regarded 
with  suspicion.  The  same  is  true  of  those  growing 
from  the  shafts  of  bones  and  the  jaws.  (  Vide  Lancet^ 
Nov.  24th,  1877.) 

Classification. — Enchondromata  may  be  divided 
into  three  groups  :  (1)  Those  growing  from  the 
metacarpal  bones  and  phalanges;  (2)  those  springing 
from  the  ends  of  the  long  bones  and  the  pelvis ;  (3) 
those  found  in  soft  tissues,  e.^.,  the  parotid  gland, 
testicle,  and  lungs. 

1.  Metacarpal  and  'phalangeal  enchondromata  are 
rarely  single.  They  commence  in  the  interior  of  the 
bones,  usually  at  the  ends.  They  seldom  grow  larger 
than  a  walnut.  They  may  calcify,  but  they  do  not 
ossify.  Their  surface  is  smooth,  or  only  very  slightly 
lobulated.  They  select  by  preference  the  periods  of 
childliood  and  youth.  They  are  perfectly  benign. 
The  matrix  is  hyaline,  or  faintly  fibrillated,  and  the 
cells  are  comparatively  small,  and  polymorphous. 

2.  Enchondromata  springing  from  the  ends  of  the 
long  hones  and  the  pelvis  often  attain  an  enormous 
size.  Coarsely  lobulated  like  fatty  tumours,  they 
differ  from  them  in  every  other  respect,  being  hard 
and  of  a  blueish-white  opalescent  appearance. 

They  grow  from  the  surface  of  the  bones,  which 
they  absorb  by  pressure  and  destroy  by  meta- 
morphosis of  tissue.  They  are  encapsuled  on  the 
surface,  but  their  structure  is  continuous  with  the 
osseous   tissue.       Coarse  fibrous   bands    carrying  the 

B    B 


4i8 


Surgical  Pathology.   [Chap.  lxxxiv. 


blood-vessels  intervene  between  the  lobules.  Nutri- 
tive changes  are  very  common,  calcification  and 
mucoid  degeneration  taking  the  lead.  The  former  is 
recognised  as  dead  white  patches  of  irregular  shape 
between  the  semi-translucent  nodules  of  cartilage. 
The  latter  causes  softening/  and  so  large  anfractuous 


Fig.  62. — Cystic  Ossifying  Encliondroma  of  the  Diaphysis  of 
the  Femur ;  from  a  Girl  cet.  17. 

%,  Cyst  bounded  above  by  an  osseous  bar;  6,  nincoid  softening  of  matrix,  anas- 
tomotic stellate  corpuscles  form  a  raeshwork  through  the  space;  c,  hyaline 
cartilage,  the  capsules  are  distended  with  mucin,    x  265. 

cavities.  They  may  ossify,  or  remain  free  from  this 
and  all  other  secondary  modifications  of  structure. 

In  the  pelvis  they  are  attached  near  the  sym- 
physis and  the  sacro-iliac  synchondrosis. 

Unlike  the  smaller  phalangeal  variety,  they  tend 
to  indefinite  increase  in  size,  but  they  resemble  them 
in  being  generally  benign. 

3.  Enchondromata  of  the  soft  tissues  are  seldom 
simple.  Thus,  mixed  "parotid  tumour"  may  contain 
cartilage  along  with  glandular,  mucous,  or  sarcomatous 


Chap.  LXXXV.]  ThE    OsTEOMATA.  419 

tissue,  one  or  more  of  them.  In  the  testicle  sarcoma 
is  rarelj  absent.  The  association  with  tumours  of  a 
lower  type  of  organisation  renders  this  group  more 
malignant  than  either  of  the  others. 

Histology. — The  matrix  is  hyaline  or  fibrous  ;  or 
it  looks  like  spun  glass.  Considerable  variation  in 
this  respect  may  be  met  with  in  the  same  tumour.  If 
calcified,  microscopical  sections  look  granular  and 
opaque  by  transmitted  light_,  but  the  capsules  and  cells 
can  again  be  brought  into  view  by  the  solvent  action 
of  a  dilute  mineral  acid.  The  cells  are  round,  oval, 
angular,  or  multipolar,  with  long  branching  offshoots. 
The  protoplasm  may  be  clear,  or  obscured  by  fat 
granules  and  drops  of  mucin  (Fig.  62).  The  entire 
cell  may  be  petrified  along  with  the  matrix. 

If  lobulated,  the  mass  is  intersected  by  vascular 
fibrous  tracts,  thus  differing  from  normal  cartilage. 
The  blood-vessels  furnish  the  lime  salts  for  calcifica- 
tion, and  hence  the  infiltration  is  more  advanced  at 
the  periphery  of  the  lobules  and  between  them  than 
in  their  interior.  In  mixed  tumours,  e.g.^  chondro- 
sarcoma, the  cartilage  is  sharply  mapped  off  from  tlie 
surrounding  tissue  (Fig.  53,  h). 


CHAPTER   LXXXY. 

THE    OSTEOMATA. 

The  osteomata  proper  are  bony  growths,  not 
dependent  upon  precedent  inflammation. 

Deposit  of  bone  is  an  accidental  or  an  integral 
part  of  many  morbid  processes  :  thus  it  is  found  as  a 
nutritive  modification  in  many  tumours,  especially 
those  springing  from  the  osseous  framework,  e.g.^  the 
sarcomata,  enchondromata,  and  fibromata.      Bone  is 


420  Surgical  Pathology.     [Chap  lxxxv. 

usually  present  in  subperiosteal  sarcomas ;  it  is  far 
from  rare  in  the  large  lobulated  cartilage  tumours 
attached  to  the  ends  of  the  long  bones  and  the  pelvis  j 
and  it  is  almost  constant  in  fibrous  epnlides.  Then, 
again,  it  is  the  final  anatomical  product  of  inflamma- 
tion of  bone  that  goes  on  to  a  natural  termination. 
In  cases  where  the  erosion  has  been  local,  and  the 
loss  of  substance  made  up  by  protuberant  granu- 
lations, the  latter  may  ossify  en  masse,  and  the  result 
simulate  the  true  non-inflammatory  exostoses ;  but,  on 
section,  the  base  of  the  new  formation  is  found  not  to 
be  limited  by  the  surface  level  of  the  bone,  but  to  lie 
some  distance  in  the  interior. 

As  in  the  osteomata  proper,  the  Haversian  canals 
of  these  inflammatory  osteophytes  lie  at  right  angles 
to  those  of  the  old  bone ;  for  ossification  follows  the 
direction  of  the  capillary  loops  in  the  outwardly 
directed  granulations. 

Muscles  and  tendons  subjected  to  much  strain  or 
irritation  are  now  and  then  extensively  ossified,  the 
bony  deposit  commencing  as  a  rule  next  the  points  of 
attachment;  e.g.,  in  the  deltoid  and  biceps  muscles  of 
infantry  soldiers  from  pressure  of  the  butt  end  of  the 
rifle,  and  in  the  adductors  of  the  thigh  of  cavalry, 
the  "  rider's  bone  "  (Rokitansky).  But  in  these  cases 
there  must  be  an  inherent  disposition  to  bone  forma- 
tion, else  it  would  be  more  common  than  it  is. 

In  like  manner,  the  bones  are  sometimes  the  seat 
of  multiple  outgrowths  at  the  points  of  origin  and 
insertion  of  the  muscles,  without  there  being  any 
ascertainable  reason  (O.  Weber). 

In  old  age  there  is  a  marked  tendency  to  ossifi- 
cation in  certain  tissues ;  e.g. ,  the  cartilages  of  the 
larynx,  trachea  and  bronchi,  the  costal  cartilages,  and 
intervertebral  ligaments.  This  is  interesting,  as 
showing  that,  whether  the  bone  formation  occurs  as  a 
new  growth  or  a  nutritive  modification  in  pre-formed 


Chap.  LXXXV.]  ThE    OsTEOMATA.  42 1 

tissue,  it  is  evidence  of  a  physiological  degeneration, 
and  serves  to  explain  the  apparent  anomaly  of 
bony  retrograde  metamorphosis  occuring  mostly  in  old 
age,  whilst  the  osseous  tumours  are  rarely  met  with 
beyond  mid-adult  life. 

The  plates  of  bone  found  in  the  meninges  of  the 
brain  and  cord  are  probably  the  consequence  of 
chi'onic  inflammation. 

Cornil  and  Kanvier  say  they  have  seen  true  bone 
in  the  calcified  adventitious  cysts  of  hydatid  tumours^ 
but  this  must  be  very  rare.  The  author  has  observed 
a  nodule  of  bone  in  the  centre  of  a  simple  hronchocele. 
Bone  is  one  of  the  multiform  contents  of  dermoid 
cysts. 

The  osteophytes  thrown  out  around  the  joints 
affected  with  tumor  alhus  and  dry  rheumatic  arthritis 
are  clearly  irritative  and  inflammatory.  In  ataxic 
arthropathy  they  are  now  and  again  met  with  as  part 
of  a  trophic  articular  lesion ;  but  M.  Charcot  informs 
me  that  they  are  quite  the  exception  in  this  disease, 
and  that  he  is  uncertain  whether  they  grow  from 
cartilage  or  not. 

Having  cleared  the  way  of  these  irregular  and 
secondary  bone  formations,  the  course  is  clear  for  the 
consideration  of 

The  osteomata,  which  almost  invariably  arise 
from  pre-existing  bone.  The  vast  majority  occur  as 
outgrowths,  or  exostoses.  A  few  occupy  the  interior  ; 
e.g.,  the  medullary  cavities  of  the  long  bones, 
enostoses ;  but  even  these  cause  projections  from  the 
surface  in  most  instances,  and  as  they  are  probably  of 
inflammatory  origin  they  will  not  be  further  discussed. 
Like  normal  bone,  the  osteomata  vary  in  density,  and 
it  is  customary  to  divide  them  into  two  groups,  the 
compact  and  spongy.  The  former  includes  the  ivory 
osteomata,  and  those  that  resemble  in  consistence  the 
outer  part  of  the  shafts  of  the  long  bones. 


42  2  Surgical  Pathology,     [chap.  lxxxv. 

Tlie  ivory  osteomata,  are  mostly  situated  on 
the  flat  bones  of  the  skull,  and  usually  on  the  inner 
surface.  They  are  found  as  plates,  or  roundish 
nodules,  composed  of  concentric  laminae  parallel  to 
the  surface  of  the  mass.  They  are  found  not  to 
contain  blood-vessels.  If  the  latter  existed  at  an 
earlier  period  of  development,  they  must  have  become 
obliterated  by  the  pressure  of  the  bony  deposit  around 
them,  in  much  the  same  way  as  syphilitic  cranial 
osteophytes  are  rendered  extra  vascular  {vide  page  217). 

The  bone  corpuscles  in  these  tumours  have  long 
outrunners,  which  are  for  the  most  part  directed 
towards  the  surface,  like  those  of  the  crusta  petrosa 
of  the  tooth  fangs  (Cornil  and  Ranvier). 

Compact  osteoraata  are  found  in  other  situations 
than  the  cranium.  In  the  College  of  Surgeons 
museum  is  a  fine  specimen  attached  to  the  lower 
jaw. 

The  spongy  osteomata  range  in  density  from 
an  open  cancellous  fretwork  to  a  closely  set  trabecular 
structure  bordering  on  the  compact  variety.  They 
grow  chiefly  from  the  ends  of  the  long  bones  in  the 
vicinity  of  the  epiphysial  cartilages.  In  all  probability 
they  start  from  the  latter,  or,  at  least,  from  the 
superjacent  periosteum.  For  this  reason  their  origin 
is  limited  to  the  term  of  existence  of  epiphysial 
growth  of  bone,  and  hence  they  are  not  found  after 
the  age  of  twenty-five  or  thirty.  The  spongy  osteomata 
are  occasionally  met  with  at  the  rough  muscular  attach- 
ments on  the  diaphyses ;  e.g..,  in  the  femur  near  the 
opening  in  the  adductor  magnus,  and  in  the  humerus 
at  the  supracondylar  ridges.  (In  some  animals  normal 
bony  projections  exist  in  these  situations  for  the  support 
and  protection  of  the  large  vessels  and  nerves.) 

The  epiphysial  osteomata  are  in  intimate  connec- 
tion with  the  cancellous  tissue  of  the  ends  of  the 
bones.     They  consist  of  rounded  or  lobulated  masses. 


Chap. Lxxxv.]  The  Osteomata.  423 

They  have  a  surface  layer  of  hyaline  cartilage,  from 
which  they  continue  to  grow,  and  this  is  covered  with 
periosteum.  Bursal  cysts  not  uncommonly  develop 
over  them,  and  by  some  pathologists  it  is  asserted 
that  these  from  the  first  are  continuous  with  the 
articular  synovial  membranes,  and  thus  constitute  a 
source  of  danger  attending  operations  upon  the  tu- 
mours in  question.  On  account  of  their  cartilaginous 
investment  the  spongy  osteomata  are  sometimes  spoken 
of  as  ossifying  enchondroTnata ;  but  this  is  not  quite 
correct,  for  when  they  cease  to  grow,  the  surface 
cartilage  may  completely  ossify ;  a  circumstance,  as 
far  as  my  observations  go,  that  never  obtains  in  un- 
doubted enchondromata.  During  their  development 
the  cartilage  capsules  are  dissolved,  and  the  pro- 
liferating cells  contained  within  are  set  free  to  form  a 
layer  of  embryonic  tissue,  and  in  this  the  ossification 
goes  on.  Whilst  the  deeper  portion  of  the  cartilage 
is  encroached  upon  and  used  up,  the  superficial  layer 
is  constantly  being  added  to. 

Microscopy, — Sections  made  vertical  to  the 
surface  show  from  without  in  :  (1)  A  fibrous  layer, 
richly  corpuscular,  next  the  cartilage;  (2)  a  narrow 
band  of  hyaline  cartilage  ;  (3)  a  stratum  of  osteogenic 
granulation  cells;  (4)  fully -formed  bone.  The  last 
has  all  the  characteristics  of  true  bone,  viz.,  Haversian 
canals,  lacunae,  and  canaliculi ;  but  the  concentric 
lamination  is  less  perfect  than  in  the  normal  tissue. 

Hereditary  multiple  osteomata.  —  These 
form  a  notable  exception  to  the  rule  that  osseous 
tumours  are  rarely  seen  in  children  under  ten  years 
of  age.  Hereditary  or  not,  the  osteomata  as  a  group 
are  not  uncommonly  multiple ;  but  the  variety  under 
notice  afiects  many  bones  of  the  body,  and  that,  too,  at 
a  very  early  age.  Fig.  63  is  a  copy  of  a  photograph 
of  a  boy  aged  ten  years,  in  whom  the  disease  is  well 
marked.     His  father  and  brother  are  afiected  in  the 


Fig.  63.— Multiple  Hereditary  Exostoses. 


Chap.  LXXXV.]  ThE    OdONTOMATA.  425 

same  way,  though  to  a  less  degree.  The  tumours  first 
appeared  when  he  was  very  young.  They  are  extremely 
hard,  and  greatl}^  interfere  with  the  movements  at 
the  joints.  Specimens  taken  from  a  similar  case,  in 
which  nearly  all  the  bones  in  the  body  were  involved, 
presented  a  nodulated  or  craggy  surface.  The  majority 
were  seated  near  to  or  on  the  epiphyses,  although 
there  were  several  exceptions  to  this.  Some  were 
pedunculated,  others  had  broad  bases  of  attachment ; 
all  were  covered  with  translucent  cartilage.  They 
would  seem  to  be  the  outcome  of  an  excessive  and  ill- 
directed  osseous  development,  comparing  in  this  way 
with  congenital  growths  ;  e.g.^  nsevi. 

The  osteomata  are  benign ;  they  do  not  recur 
after  complete  removal ;  and  although  sometimes 
multiple,  they  do  not  generalise.  After  a  time  they 
cease  to  grow.  In  themselves  they  are  painless 
They  cause  annoyance  by  their  unsightliness,  by  the 
occasional  occurrence  of  inflammation  and  ulceration 
of  the  skin  over  them,  and  by  their  impeding  move- 
ment. They  should  not  be  removed  except  under 
urgent  necessity,  and  this  applies  particularly  to  the 
spongy  osteomata  about  the  joints. 

The  odontomata  are  made  to  include  inflamma- 
tory exostoses  growing  from  the  crusta  petrosa  of  the 
fangs;  but  the  term  should  be  confined  to  tumours  of 
new  formation,  that  consist  of  one  or  more  of  the  dental 
tissues.  Of  these  there  are  three  varieties :  (1)  Enamel 
plates  situated  usually  about  the  neck  of  the  tooth. 
They  are  small,  and  look  like  pearly  drops  of  congealed 
wax.  They  give  rise  to  no  symptoms.  (2)  Dentine 
tubercles  projecting  into  the  pulp  cavity.  They  are 
only  recognised  after  extraction  for  neuralgia.  (3) 
"  Warty  teeth "  or  "  dentinal  odontomes  "  (Broca). 
These  are  the  most  important  of  dental  tumours. 
They  grow  from  the  neck  or  fang,  and  form  lobulated 
masses  embedded  in  the  jaw,  which  they  absorb  by 


426  Surgical  Pathology.     [Chap.  lxxxv. 

their  pressure  j  or  projecting  from  the  teeth  sockets. 
Billroth  figures  one  more  than  an  inch  in  diameter. 
Their  structure  is  made  up  of  one  or  more  of 
the  tooth  elements.  Usually  there  is  an  admix- 
ture of  bone  with  irregularly  disposed  dentine  or 
enamel. 

Osteoid  tiimour. — Yirchow  has  described  a 
new  formation,  the  fundamental  structure  of  which  is 
identical  with  the  "  osteoid  tissue  "  found  beneath  the 
periosteum  in  rickets.  ( F^io^e  Rickets. )  These  growths 
are  smooth  or  lobulated.  They  may  attain  considerable 
size.  Clinically  they  are  more  nearly  related  to  the 
sarcomata  than  to  the  osteomata,  for  they  generalise  in 
the  internal  organs.  They  consist  of  spongy  bone 
tissue,  with  an  uncertain  amount  of  embryonic,  fibrous, 
or  cartilaginous  material ;  hence  they  may,  by  the 
unaided  eye,  be  mistaken  for  tumours  composed  of  one 
or  other  of  these  last-named  tissues. 

Microscopy.  —  Trabeculse  of  various  sizes  and 
shapes  alternate  with  layers  of  connective  tissue. 
They  consist  of  a  homogeneous  or  faintly  fibrillated 
matrix  in  which  angular  corpuscles  are  embedded. 
These  corpuscles  have  only  short  processes,  and  do  not 
form  a  lacunar  inosculating  system  as  in  true  bone, 
although  the  spaces  in  which  they  lie  are  said  to  join 
minute  channels  in  the  intertrabecular  tissue.  The 
matrix  is  often  calcified  in  patches,  or  it  may  be  in  its 
entirety.  The  fibrous  tissue  between  the  trabecules 
carries  the  blood-vessels  for  the  support  and  growth  of 
the  tumour.  In  it  islets  of  cartilage  are  distributed, 
and  when  in  large  amount  the  name  "  osteoid 
chondroma"  is  given  to  it.  According  to  Yirchow, 
the  osteoid  tissue  is  not  confined  to  new  growths  and 
rickets,  but  is  met  with  in  a  minor  degree  beneath  the 
periosteum  during  the  normal  development  of  bone. 
If  this  be  so,  it  goes  to  show  that  the  tumours  under 
consideration  are  built  upon  the  type  of  embryonic 


Chap.  Lxxxvi.]         The  Myxomata.  427 

tissue  of  a  specialised  form,  and  to  confirm  the  view  of 
their  histological  relationship  with  the  sarcomata. 


CHAPTER    LXXXVI. 

THE    MYXOMATA. 

When  treating  of  mucoid  degeneration  it  was 
pointed  out  that  certain  tumours,  especially  the 
sarcomata,  were  liable  to  undergo  this  change ;  and 
that  it  lay  at  the  foundation  of  true  cystic  development. 
{Vide  Fig,  5.)  But  the  term  myxoma  indicates  thase 
growths  in  which  the  embryonic  tissue  necessarily 
passes  to  the  next  place  of  organisation,  or  that 
between  indifferent  cell  -  growth  and  fully  formed 
connective  tissue. 

Their  physiological  type  occurs  widely  distributed 
in  the  foetus,  and  in  the  permanent  mucous  tissue  of 
the  vitreous  humour  and  umbilical  cord.  The  pure 
myxomata  are  generally  benign,  having  but  little 
tendency  to  recur  after  complete  removal,  or  to 
generalise  in  distant  parts. 

This  does  not  hold  good  concerning  some  mixed 
tumours,  of  which  mucous  tissue  is  a  constituent,  e.g.^ 
myxo-sarcoma.  The  gravity  of  these  cases  depends 
upon  the  more  malignant  element  and  the  proportion 
it  bears  to  the  whole  tumour.  And  there  is  this  to  be 
said,  that  a  myxoma,  representing  as  it  does  develop- 
mental tissue,  is  more  likely  than  other  simple  tumours 
to  revert  to  the  embryonic  type  and  become  malignant. 
The  association  may  be  manifested  quite  early,  or  it 
may  only  show  itself  after  a  long  interval. 

To  the  naked  eye  the  myxomata  appear  as  semi- 
translucent    gelatinous    masses,     of    pretty    uniform 


428  Surgical  Pathology.    [Chap. lxxxvi. 

consistence  and  colour,  unless  perchance  they  be 
varied  by  patches  of  hsemorrhage,  and  softening  from 
fatty  degeneration  and  liquefaction  of  the  inter- 
cellular substance.  A  glairy  glutinous  fluid  is  obtained 
by  scraping ;  this  consists  of  mucin  mixed  with  cells 
of  the  gro^vth,  and  blood  corjDuscles.  It  is  very 
different  from  the  lactescent  juice  of  cancers.  The 
greater  number  grow  from  the  mucous  membranes  in 
the  form  of  polypi,  or  from  connective  tissue.  They 
are  also  found  in  the  voluntary  muscles.  According 
to  Virchow,  hydatid  moles  of  the  placenta  are  of  the 
same  nature.  These  monilif  orm  growths  start  from  the 
chorionic  villi,  which  consist  normally  of  mucous  tissue. 
Many  of  the  so-called  neuromata  are  really  myxomata, 
springing  from  the  connective  tissue  of  the  nerves,  the 
fibres  of  which  are  usually  spread  over  the  surface  of 
the  tumour,  though  occasionally  they  pass  through  the 
centre.  There  may  be  one  or  more;  when  multiple  they 
are  distributed  over  the  branches  of  a  nerve  or  nerve 
plexus.  They  are  exceedingly  painful  from  stretching 
of  the  nerve-fibres. 

Similar  growths  implicate  the  nerve  centres.  We 
have  met  with  them  both  in  the  brain  and  spinal 
cord,  in  each  instance  arising  apparently  from  the 
membranes. 

The  myxomata  are  chiefly  found  in  early  life, 
especially  the  polypoid  variety. 

Nasal  mucous  polj-pi  are  nearly  always  mul- 
tiple. They  are  attached  almost  exclusively  to  the 
outer  walls  of  the  nasal  foss?e.  In  aspect  they  are 
grey  and  glistening.  A  thin  watery  mucus  exudes 
from  their  surface.  They  difler  from  the  succulent 
fleshy  •'  nasopharyngeal  polypi  "  as  follows  :  (1)  They 
grow  from  the  mucous  membrane  and  not  from  the 
periosteum ;  (2)  their  pedicles  are  very  narrow, 
often  filamentous ;  (3)  when  completely  removed  they 
do  not   recur;    (4)   they  do   not  absorb  and  destroy 


Chap.  LXXXVI.l 


The  Myxomata. 


429 


neighbouring  structures.  Though  one  operation  may 
not  suffice  for  a  cure,  it  does  not  point  to  a  "  recur- 
rence "  in  the  ordinary  acceptation  of  the  term,  but  to 
the  existence  of  other  polypi  too  small  to  be  grasped 
by  the  forceps. 

Microscopy.— All  possess  a  homogeneous  gelati- 
nous intercellular  substance.     The  cells  embedded  in 


/^ 


Fig.  64. — Mucous  Polypus  of  the  Bladder. 

a.  Squamous  epithelium ;  6,  blood-vessel ;  c,  stellate  corpuscle ;  d,  nucleus  of 
corpuscle.    X  300.    (.See  Fig.  06.) 

this  are  round  and  oval  in  some  specimens  ;  stellate, 
branched,  anastomotic  in  others,  the  outrunners 
forming  a  delicate  plexus  of  fibres  throughout  the 
growth.  But  in  by  far  the  greater  majority  the  cells 
are  polymorphous,  round,  oval,  stellate  in  varying 
proportions.  This  is  well  seen  in  Fig.  64,  taken  from 
a  rare  specimen  of  mucous  polypus  of  the  bladder  (Fig. 
56).  Unless  the  section  be  stained  the  cells  are  barely 


430  Surgical  Pathology.  [Chap.  lxxxvii. 

visible,  since  tlieir  refractive  index  is  nearly  that  of 
the  ground  substance.  The  myxomata  growing  in 
connective  tissue  have,  as  a  rule,  a  thin  capsule. 
Mucous  polypi  are  covered  with  epithelium,  like  that 
of  the  region  in  which  they  are  found.  Thus,  in 
the  bladder  the  superficial  cells  at  least  are  flattened. 
In  the  nose  they  are  columnar  and  ciliated. 

The  blood-vessels  are  easily  observed.  They  have 
distinct  walls,  but,  the  lateral  support  being  unstable, 
they  easily  rupture,  hence  the  frequency  of  capillary 
haemorrhages  into  the  growth. 

Elastic  fibres  and  fat  cells  are  sometimes  present, 
so  are  cysts.  Occasionally  in  mucous  polypi  glandular 
prolongations  can  be  traced  from  the  surface  inwards. 
In  them,  too,  subject  as  they  are  to  physical  injury, 
nutritive  modifications  are  far  from  rare — haemorrhages, 
inflammation,  and  gangrene  from  bruising  or  twisting 
of  their  pedicles. 


CHAPTEU   LXXXVII. 

THE    NEUROMATA. 

Most  of  the  tumours  designated  neuromata  are 
either  fibromata  or  myxomata  growing  from  the  con- 
nective tissue  of  the  nerves.  True  neuromata  are 
always  homologous,  and  never  generalise,  although 
they  may  be  multiple.  They  contain  nerve- fibres  of 
new  formation.  There  are  two  varieties^  according 
as  they  contain  medullated  or  non-meduUated  fibres, 
the  myeline  and  amyeline  neuromata  of  Virchow. 
Nerve  cells  are  only  met  with  in  the  tumours  springing 
from  the  cerebral  or  spinal  centres,  and  in  some 
dermoid  cysts  of  the  ovary. 


Chap.  Lxxxvii.]         TheMyomata.  43 1 

Mediillated  or  fascicular  neiu^oanata    are 

much  more  common  than  the  non-meclullated,  but  both 
are  rare.  The  best  example  is  seen  in  the  clubbed 
extremities  of  the  nerves  in  amputation  stumps.  In 
the  regeneration  of  divided  or  wounded  nerves,  new 
fibres  are  developed  either  from  the  elongation  of  the 
proximal  ends  of  the  severed  fibres  or  from  the  con- 
version of  the  fusiform  cells  of  the  granulation  tissue. 
The  latter  is  more  probable,  as  it  explains  the  mode 
of  formation  of  cicatricial  neuromata.  Even  here  the 
greater  part  of  the  enlargement  consists  of  dense 
fibrous-tissue.  On  strict  pathological  grounds  these 
bulbous  ends  of  nerves  should  be  relegated  to  the 
inflammatory  new  formations.  A  similar  develop- 
ment of  nerve-fibres  is  now  and  then  met  with  in  the 
continuity  of  nerve  trunks,  where  it  gives  rise  to 
fusiform  swellings.  MeduUated  nerve -fibres  are 
occasionally  met  with  in  dermoid  cysts. 

Non-mediillatecl  or  amyeline  neuromata 
are  described  by  Yirchow  as  occurring  in  connection 
with  the  brain  and  spinal  cord.  They  contain  Ee- 
mak's  fibres,  neuroglia,  and  nerve  cells.  The  isolated 
patches  of  nerve  tissue  found  in  some  congenital 
encephaloceles  are  probably  the  remains  of  herniated 
brain  substance,  and  not  new  formations.  The 
bulgings  of  the  spinal  cord  on  division  of  the  mem- 
branes must  not  be  mistaken  for  neuromata. 

Non-meduUated  nerve-fibres  are  developed  in  some 
dermoid  cysts. 

The  so-called  neuromata  of  the  optic  nerve  are 
either  mucous  or  gliomatous  tumours. 

The  Myomata. 

Tumours  composed  of  muscular  tissue  alone  are 
very  rare,  but  complex  growths  of  which  it  is  a  con- 
stituent are  more  common. 

There  are  two  varieties^  striped  and  unstriped. 


43.2 


Surgical  Pathology.  [Chap. lxxxvii. 


(1)  Myomata  with  smooth  fibres. — These  are  always 
found  in  connection  with  the  muscles  of  organic  life. 
The  best  examples  are  those  growing  from  the  uterus 
and  alimentary  canal.  In  these  situations  they  are 
cither  embedded  in  the  muscular  walls,  or  project 
beneath  the  mucous  or  serous  membrane  in  the  form 
of  polypi.  The  submucous  and  subperitoneal  myo- 
mata are  probably  intramural  in  their  origin,  and  are 

forced  to  the  surface 
by  the  contraction  of 
the  muscles  in  which 
I    they  are  developed. 

Uterine  myomata 
are  often  very  large, 
filling  and  distending 
the  cavity  of  the 
uterus,  or  occupying 
the  pehTLS  and  abdo- 
men external  to  that 
organ.  Fibrous  tissue 
enters  largely  into 
their  composition,  and 
eventually  may  so  ex- 
ceed the  muscular  elements  as  apparently  to  obliterate 
them.  On  this  account  some  pathologists  class  these 
tumours  with  the  fibromata,  or  notify  their  doubtful 
nature  by  the  term  "fibroid."  They  are  more  cor- 
rectly described  as  fibro-myomata  or  myo-fibromata 
(Fig.  65),  The  muscular  fibre-cells  can  be  dissociated 
from  the  connective  tissue  by  dissolving  the  latter  in  a 
20  per  cent,  solution  of  nitric  acid. 

These  myomata  are  smooth  or  lobulated.  On 
section  they  are  seen  to  consist  of  interlacing  bundles 
of  fibres,  which  often  form  concentric  nodules ;  con- 
nective tissue  carrying  blood-vessels  fills  up  the  in- 
tervals between  the  muscular  fasciculi.  They  are  gene- 
rally circumscribed,  and  even  when  dififiise  they  are 


Fig.  65. — Myo-Fibroma  of  Uterus 

a,  Transversa  section  of  himdle  of  muscular 
fibres  embedded  in  connective  tissue,  b. 
The  tumour  was  as  hard  as  cartilage. 
X  265. 


Chap.  Lxxxvii.]         The  Myomata.  433 

surrounded  by  a  capsule.  They  are  for  the  most  part 
very  firm,  and  creak  on  being  cut  with  a  knife ;  but 
a  few  are  more  succulent  and  contain  large  dilated 
vessels. 

In  the  oesophagus,  stomach,  and  intestine  unstriped 
myomata  are  occasionally  seen  as  small  interstitial 
nodules  or  submucous  polypi.  Like  the  uterine 
growths,  they  may  be  single  or  multiple. 

Muscular  fibre  is  largely  developed  in  the  prostate 
glands  of  old  men,  as  part  of  a  difFuise  hypertrophy,  or 
as  a  circumscribed  tumour.      (Vide  Adenoid  growths. ) 

Nuti^itive  modifications. — (1)  Calcification  is  very 
common,  especially  in  "uterine  fibroids."  The  author 
once  saw  a  completely  petrified  uterine  myo-fibroma. 
It  was  as  large  as  a  cricket  ball,  and  was  attached  to 
the  uterus  by  a  fibrous  pedicle  a  foot  long.  (By 
the  twisting  of  such  pedicle  the  vessels  supplying  the 
tumour  may  be  strangulated.)  (2)  FcUty  degeneration 
usually  accompanies  calcification.  (3)  Mucoid  soften- 
ing occurs  sometimes,  and  gives  rise  to  regular  cysts 
or  large  anfractuous  cavities. 

Clinically  these  tumours  are  benign,  but  they  may 
be  serious  on  account  of  the  haemorrhage  they  occasion 
and  the  mechanical  interference  with  the  functions  of 
organs.  In  one  case  a  uterine  fibroid  caused  fatal 
obstruction  of  the  bowels  by  clamping  the  rectum 
against  the  brim  of  the  true  pelvis. 

Myomata  wdth  striped  fibre*. — These  are  in- 
finitely rarer  than  the  preceding.  They  are  seldom, 
if  ever,  found  as  simple  tumours.  Striped  muscular 
fibres  enter  into  the  composition  of  some  complex 
cystic  formations  in  the  ovary,  and  of  some  congenital 
tumours  of  other  parts.  The  author  was  shown  a 
sarcoma  of  the  kidney  by  Mr.  W.  Pye,  in  which  they 
were  beautifully  developed. 

The  unstriped  myomata  are  homologous  in  their 
origin,  the  striped  variety  usually  heterologous. 

c  c 


434 


CHAPTER  LXXXYIII. 

THE    ANGIOMATA. 

Type  :  blood-vessels. — They  mTist  be  distingmshed 
from  aneurisms  and  varices,  which  are  only  dilatations 
of  pre  -  existing  vessels.  It  is  doubtful  whether 
aneurism  by  anastomosis  should  be  included  in  this 
group;  probably  not,  for  there  is  want  of  proof  that 
they  consist  of  other  than  general  and  varicose 
dilatation. 

There  are  two  species  of  angioma  :  (1)  simple,  (2) 
cavernous. 

(1)  Simple  angiomata;  telangiectases; 
congenital  nsevi. — These  affect  the  skin  and 
subcutaneous  tissue.  They  appear  at  or  soon  after 
birth,  and  increase  by  new  formation  of  vessels.  In 
colour  they  vary,  being  scarlet,  purple,  or  blue,  accord- 
ing to  the  proportion  severally  of  arteries,  capillaries, 
and  veins  that  enter  into  their  composition  ;  and  to 
the  rate  of  the  blood  current  through  them.  They  are 
most  common  about  the  face  and  neck.  They  form 
soft  spongy  swellings,  imbedded  in  the  skin,  or  raised 
from  the  surface  as  broad  sessile  elevations.  They 
are  composed  of  a  number  of  flexuous  intertwining 
vessels,  held  together  by  a  scanty  amount  of  areolar 
tissue.  The  vessels  for  the  most  part  consist  of  capil- 
laries, marked  here  and  there  with  lateral  loops  and 
ampuUary  dilatations.  Their  walls,  which  are  very 
delicate,  are  constructed  of  elongated  cells.  Muscular 
fibres  are  developed  in  some  of  the  older  and  larger 
vessels ;  in  fact,  there  may  be  well-formed  arteries 
and  veins. 


Chap.  LXXXVIIIJ        ThE    AnGIOMATA. 


435 


(2)  Cavernous  angiomsita ;  venous  naevi 
erectile  tumours  (Dupuytren). — They  are  situated 
chiefly  in  and  beneath  the  skin,  but  they  are  also  found 
in  the  orbit  and  in  the  internal  organs,  e.g.,  the  liver 
(Yirchow).  On  the  cutaneous  surface  they  appear 
bluish.  They  can  be  greatly  reduced  in  size  by 
pressure.  They  sometimes  pulsate.  In  children  fat 
often  enters  largely  into  their  composition  (nsevoid 
lipomata). 

The  vessels  form  a  system  of  wide  intersecting 
canals,  alternating  with  trabeculse  of  connective  tissue, 
reminding  one 
of  the  alveolar 
arrangement  in 
carcinoma.  They 
are  lined  with 
fusiform  endo- 
thelial cells. 
Their  walls  con- 
sist of  the  fibrous 
tissue  of  the 
stroma,  and 
sometimes  con- 
tain muscular 
fibres    and     fat 

cells,    but    there  y\%.  66.— Subcutaneous  Venous  Nsevus. 

are  no  regularly  «,  Fibrous  stroma ;  h,  vascular  canal,    x  200. 

arranged  tunics.  The  stroma  is  said  to  possess 
vasa-vasorum  and  even  nerves  (Esmarch),  but 
the  latter  are  probably  the  remains  of  the  normal 
tissue  invaded  by  the  growth.  The  blood  spaces 
show  a  natural  injection  {vide  Fig.  66)  in  sections 
hardened  by  alcohol.  The  cavernous  system  is  formed 
by  dilatation  of  the  vessels  and  by  absorption  of 
their  walls.  Where  development  is  active  the  vessels 
are  small  as  compared  with  the  width  of  the  inter- 
vening connective  tissue  trabeculse,  but  subsequently 


436  Surgical  Pathology.   I^chap. lxxxviii. 

this  disparity  is  reversed.  Kindfleisch  explains  it  by 
assuming  that  of  two  sets  of  intersecting  columns  (in 
this  case  represented  by  blood  and  connective  tissue 
respectively),  if  one  shrinks  the  other  becomes 
enlarged.  But  any  contraction  of  the  stroma  must 
be  interstitial,  and  pretty  equal  in  all  directions,  and 
therefore  cause  a  diminution  in  the  calibre  of  the 
vessels;  besides  in  cirrhosis  of  the  liver,  and  in  the 
cicatrisation  of  wounds,  many  of  the  capillaries  are 
strangulated  and  finally  obliterated.  It  seems 
more  probable,  then,  that  the  enlargement  of  the 
vessels  in  angioma  takes  place  at  the  expense  of 
the  stroma,  and  that  the  atrophy  of  the  latter  is 
due  to  the  pressure  of  the  blood  in  the  cavernous 
spaces. 

New  vessels  are  formed  by  csecal  protrusions  from 
those  already  in  existence.  It  is  possible  that  some 
are  developed  from  formative  cells,  as  in  the  organisa- 
tion of  blood  clots  and  inflammatory  exudations,  and 
that  later  on  they  join  one  another  and  the  vessels  of 
the  initial  growth. 

When  the  vessels  increase  rapidly  in  size  and 
number  they  are  surrounded  by  a  richly  corpuscular 
tissue,  and  the  growth  may  then  simulate  a  sarcoma. 
On  the  other  hand,  vascular  pulsatile  sarcomatous 
tumours  of  bone  have  been  erroneously  considered  as 
''aneurism  "  or  angioma. 

Secondary  cliang'es. — (1)  Calcification  occurs 
now  and  then  in  the  walls  of  cavernous  nsevi ;  (2) 
cysts  may  form  by  the  expansion  of  the  walls  of  one 
or  more  of  the  vessels  after  the  latter  have  been 
strangulated,  and  occluded  by  coagula.  The  contents 
of  such  cysts  consist  of  liquefied  clot  and  serous 
exudation  (E.  Wagner). 

(3)  The  tumour  may  cease  to  grow,  and  shrink 
to  a  fleshy  fibrous  mass,  "  degenerated  nsevus ;  "  this 
is  chiefly  seen  in  the  scalp. 


Chap.  Lxxxix.]        The  Sarcomata.  437 

It  may  be  noted  tliat   "vascular    tumour  of  tlie 
meatus  urinarius  "  is  nsevoid  in  its  nature. 


CHAPTEE    LXXXIX. 

THE    SARCOMATA. 

The  sarcomata  are  tumours  that  liave  their 
type  in  embryonic  connective  tissue.  The  simplest 
form  is  that  consisting  of  an  aggregation  of  round 
cells  held  together  by  a  scanty  homogeneous  sub- 
stance and  traversed  by  capillary  blood-vessels.  It  is 
impossible,  from  a  microscopical  examination  alone,  to 
tell  it  from  inflammatory  granulation  tissue  ;  in  fact, 
it  is  sometimes  called  "granulation  sarcoma."  More 
frequently,  however,  the  growth  is  not  so  primitive  in 
structure ;  the  cells  enlarge  and  elongate,  becoming 
spindle-shaped  ;  or  fibrous  tissue  is  found  more  or  less 
abundantly;  or  nodules  of  cartilage  spring  up  here  and 
there,  and  so  on,  until  the  most  diversified  group  of 
tumours  is  completed. 

Whatever  modification  they  undergo,  with  a  few 
I'are  exceptions,  they  do  not  assume  that  regular 
alveolar  arrangement  so  characteristic  of  cancers. 
Having  their  type  in  embryonic  tissue,  they  tend  to 
follow  it  in  the  same  lines  of  development,  but  they 
differ  from  it  in  that  they  never  reach  finality  of 
growth,  for  there  is  no  end  to  their  formative  activity. 

The  cells  of  which  they  are  chiefly  composed  vary 
much  in  size  and  shape.  Most  commonly  they  are 
round  or  fusiform ;  but  in  the  central  sarcomas  of 
bone  large  numbers  are  naked  masses  of  protoplasm, 
with,  it  may  be,  as  many  as  twenty  nuclei. 

They  may  become  so  attenuated  that  when  closely 


438  Surgical  Pathology.   [Chap.  lxxxix. 

packed  tliey  appear  at  first  sight  like  bundles  of 
fibrous  tissue. 

Yariouslj  shaped  cells  are  often  found  in  the  same 
section. 

The  nutritive  modifications  are  more  numerous 
than  in  any  other  class  of  tumours;  e.g.,  melanosis 
is  much  more  common  than  in  cancers.  Mucoid  de- 
generation accounts  for  the  frequency  of  essential 
cysts  ;  essential,  inasmuch  as  many  arise,  not  from 
accidental  rupture  of  vessels,  nor  from  liquefaction 
by  fatty  degeneration  from  deficiency  of  nutriment, 
but  from  certain  cells  set  a^oart  for  this  inherent  trans- 
formation. 

The  intercellular  substance  varies  much  in 
amount  and  form.  In  some  cases  {e.g.,  the  round 
and  large  spindle-celled  varieties)  the  cells  appear  in 
actual  contact  ]  in  others,  composed  mainly  of  small 
spindle  cells,  the  matrix  is  often  very  abundant,  and  is 
homogeneous  or  fibrillated.  In  lympho-sarcoma  there 
is  a  delicate  reticuluni  of  fibres  between  the  cells, 
resembling  the  tissue  of  a  lymphatic  gland ;  and  in 
glioma  of  the  nerve  centres  and  retina  a  similar 
arrangement  is  found.  It  is  subject  to  calcification 
aud  other  chansjes. 

Blood-vessels  traverse  the  tumour  in  all  direc- 
tions. Their  walls  are  very  thin,  and  are  constructed 
by  the  cells  of  the  growth,  elongated  perhaps,  and 
arranged  end  to  end,  but  never  forming  distinct  coats. 
They  readily  dilate  and  rupture  ;  hence  aneurismal 
pouches,  haemorrhages,  and  disseminations. 

From  the  frequent  admixture  of  other  than  em- 
bryonic elements,  sarcomas  form  composite  tumours  ; 
the  terms  myo-sarcoma,  fibro-sarcoma,  and  chondro- 
sarcoma explain  themselves. 

Although  any  variety  may  be  found  in  any  tissue, 
there  is  still  a  well-marked  tendency  in  many  instances 
to  affect  certain  structures ;  thus,  the  pigmented  form 


Chap.  LXXXIX.]  ThE    SaRCOMATA,  439 

is  mostly  found  in  the  choroid  and  skin  ;  the  cystic 
in  the  bones,  testicle,  and  breast ;  the  myeloid  in 
cancellous  bone ;  the  round,  mixed,  and  spindle- 
celled  growing  from  bones  and  fascise. 

Sarcomas  destroy  the  tissues  in  which  they  grow  in 
three  ways  :  (1)  By  direct  pressure,  causing  atrophy 
in  the  same  way  as  an  aneurism  ;  (2)  by  infiltration  ; 
(3)  by  compression  or  invasion  of  large  vessels. 

When  the  growth  in  a  bone  is  central,  we  often 
find  expansion  with  the  wasting,  which  accounts  for  the 
"  egg-shell  "  crackling  over  such  tumours,  especially  in 
the  jaws ;  and  for  some  of  the  so-called  spontaneous 
fractures  of  the  long  bones. 

When  pulsatile,  and  situated  in  the  regions  of 
large  arteries,  e.g.,  the  popliteal  space  or  the  pelvis, 
it  may  be  difiicult  to  diagnose  them  from  aneurisms, 
for  they  give  a  distinct  bruit  and  thrill ;  the  latter 
signs,  however,  are  more  uniformly  diffused  in  sar- 
coma, and  the  murmur  is  not  conducted  along  the 
main  artery ;  again,  they  cannot  be  so  easily  emptied  by 
pressure.     They  do  not  refill  so  suddenly  as  aneurisms. 

The  pulsation  is  increased  by  the  formation  of 
aneurismal  dilations  of  the  vessels,  and  hence  sarcomas 
of  bone  are  often  described  as  "  aneurisms  ofhone.^' 

Sarcomas  springing  from  the  surface  of  bones 
present  a  radiating  appearance  (Fig.  29),  from  the 
centrifugal  direction  of  the  blood  pressure,  and  when 
ossification  occurs  the  new  bone  often  follows  the 
same  lines  in  the  form  of  delicate  feathery  sprays. 

Varieties  of  sarcoma.  —  These  are  based, 
firstly,  upon  the  shape  of  the  cells  that  predominate 
in  the  tumour  (round-celled,  spindle-celled,  myeloid)  ; 
secondly,  upon  some  modification  of  structure,  either 
in  the  arrangement  of  the  cells  and  disposition  of  the 
intercellular  substance  (lympho-sarcoma,  alveolar  sar- 
coma), or  from  admixture  with  other  than  embryonic 
tissue  (chondro-sarcoma,  osteo-sarcoma) ;  thirdly,  upon 


440  Surgical  Pathology.   [Chap.  lxxxix. 

some  nutritive  change  (melanotic  sarcoma,  cystic  sar^ 
coma). 

As  to  relative  malignancy,  round  -  celled  sar- 
coma takes  the  lead ;  for  the  whole  of  the  vital 
energy  of  the  tumour  is  expended  in  growth,  to  the 
exclusion  of  a  higher  development.  Next  .comes  the 
large  spindle-celled  variety,  the  cells  of  which  are 
closely  packed,  there  being  but  little  ground  sub- 
stance. Then^  in  order,  are  the  mixed  round  and 
spindle-celled,  the  small  spindle-celled,  and  the  myeloid 
or  giant-celled.  The  melanotic  and  alveolar  are,  as  a 
rule,  very  malignant. 

Chondrifying  and  ossifying  sarcomas  are  malignant 
in  proportion  to  the  amount  of  embryonic  tissue  they 
contain. 

(1)  Round-celled  sarcoma,  embryo-plastic 
tumour  (Lebert),  enceplialoid  sarcoma  (Cornil 
and  Ranvier). — Of  this  there  are  two  varieties,  small 
and  large-celled.  They  are  of  very  rapid  growth, 
often  ending  fatally  in  a  few  months,  especially  in 
children,  the  formative  activity  of  whose  tissues  is 
very  great. 

They  are  of  soft,  brain-like  consistence,  of  a 
pinkish-grey  or  yellowish-white  colour.  The  walls 
of  the  vessels  being  very  thin  and  badly  supported, 
rupture  spontaneously,  or  on  the  slightest  pressure, 
giving  rise  to  patches  of  extravasation,  or  even  large 
blood  cysts.  Having  gained  the  surface,  they  form 
the  so-called  "  fungus  hsematodes,"  from  their  rapidity 
of  growth  and  tendency  to  bleed  (the  same  name  is 
applied  to  fungating  encejDhaloid  cancer).  The  multi- 
plication of  the  cells  outstripping  the  formation  of 
vessels  for  their  support,  and  the  acute  interruption  of 
nutrition  from  rupture  of  capillaries,  lead  to  fatty 
degeneration  and  death  of  the  cells,  the  softened 
debris  mixed  with  blood  forming  a  grumous  pulta- 
ceous  mass.     Their  elasticity  may  easily  be  mistaken 


Chap.  LXXXIX.]        SpINDLE-CELLED    SaRCOMA.  44 1 

for  the  fl actuation  of  an  abscess,  but  on  passing  a 
trochar  little  but  blood  escapes.  They  infiltrate  the 
surrounding  tissues,  so  that  remoTal  is  difficult  and 
recurrence  rapid  and  certain.  They  generalise  in  the 
internal  organs,  in  the  lymphatic  glands,  and  even  in 
bone  ;  but  death  may  supervene  so  shortly  that  there 
may  not  be  time  for  secondary  growths  to  appear. 
They  aflect  almost  all  the  tissues,  but  the  skin,  bones, 
and  fascise  are  their  seats  of  election.  IMicroscopically, 
they  consist  for  the  most  part  of  simple  embryonic 
cells,  embedded  in  a  scanty  homogeneous  or  granular 
matrix.  Sometimes  the  cells  are  more  voluminous, 
with  large  bright  nuclei. 

(2)  Spindle-celled  sarcoma. — Of    this    there 
are  two  varieties,  the  large  and  the  small-celled.     The 


rig.  67. — Large  Spindle-celled  Sarcoma  from  the  Fascia  Lata  of 
the  Thigh. 

a,  Spindle  cells  wltli  fusiform  nuclei :  6,  bundle  of  spindle  cells  in  transverse 

section,     x  265. 


large  spindle-celled  consists  of  long,  tapering  cells 
(Fig.  67),  closely  packed  in  a  scanty  homogeneous 
substance.  The  cells  contain  one  or  more  nuclei  and 
nucleoli.  As  they  show  little  or  no  tendency  to  form 
fibrous  tissue,  they  are  much  softer  and  more  malignant 
than  the  small-celled  variety.  The  small  spindle- 
celled  sarcomas  include  the  "fibroplastic  tumour"  of 


442  Surgical  Pathology.    [Chap,  lxxxix. 

Lebert  and  tlie  "  recurrent  fibroid  "  of  Paget.  The 
relative  amount  of  cells  and  intercellular  substance 
varies  greatly ;  in  some  the  cells  constitute  the  main 
part  of  the  tumour ;  in  others  they  are  embedded  in 
a  large  quantity  of  ground  material,  homogeneous, 
granular,  or  fibrillated.  Their  appearance  on  section, 
rate  of  growth,  and  malignancy  will  thus  differ  with- 
in very  wide  limits ;  they  may  run  closely  the  large- 
celled  variety  in  gravity,  or  they  may  approach  the 
simple  fibromata.  It  may  be  here  noted  that  the 
unstriped  myomata  and  the  fibromata  in  the  early 
stages  of  their  growth  contain  fusiform  cells  which 
cannot  be  distinguished  from  those  of  sarcomas ;  we 
must  then  turn  to  other  portions  of  the  same  specimen, 
or  wait  for  the  further  development  of  the  tumour,  to 
decide  upon  its  real  nature. 

The  majority  of  small  spindle-celled  sarcomas  are 
firm  in  consistence,  generally  encapsuled,  and  thus 
non-infiltrating.  On  section,  they  appear  of  a  greyish- 
white  colour,  and  are  seen  to  be  traversed  by  inter- 
secting bands  of  what  appears  like  fibrous  tissue. 
However  hard,  they  do  not  retract  and  cup  in  the 
centre  like  scirrhous  cancer;  for  their  density 
is  more  uniform  throughout.  They  grow  from 
the  bones,  fasciae,  muscles,  aiid  connective  tissue 
generally.  When  they  recur  after  removal,  succes- 
sive growths  are  liable  to  be  softer  and  more  cellular 
than  their  predecessors,  so  that  it  is  not  uncommon 
for  the  intervals  of  immunity  to  get  shorter  and 
shorter.  They  generalise  in  the  internal  organs, 
but  the  lymphatic  glands  are  rarely  affected.  After 
several  years,  death  may  ensue  from  exhaustion 
from  operations  and  ulceration  of  the  tumour,  and 
not  a  secondary  growth  be  found.  Finally,  the  cure 
may  be  complete  after  one  or  more  removals. 

They  may  ossify  or  calcify,  more  frequently  the 
latter.     If   the   lime   salts  be  dissolved  out,  the  true 


Chap.  LXXXIX.] 


The  Sarcomata, 


443 


structure  becomes  manifest  on  section ;  cells  which 
were  before  hidden  by  the  petrification  are  brought 
into  view. 

(3)  Mixed  round  and  spindle-celled  sar- 
comas are  very  common.  Their  characters  depend 
to  a  great  extent  on  the  proportion  of  round  to  spindle 
cells. 

(4)  Myeloid,  or  giant-celled  sarcomas,  with 
very  few  exceptions,  grow  from  bone,  and  that  too  from 
the  cancellous  tissue.  Their  favourite  seats  are  the  jaws 
and  the  ends  of  the 
long  bones,  especially 
the  upper  end  of  the 
tibia  and  lower  end 
of  the  femur,  radius, 
and  ulna. 

In  the  jaws  they 
are  either  central,  or 
they  project  from  the 
sockets  of  the  teeth 
as  epulides.  When 
central  the  pressure 
of  the  growth  causes 
atrophy  of  the  com- 
pact laminae ;  but' 
this  is  partly  com- 
pensated by  tlie  de- 
posit of  new  bone  on 
the  outside  from  the 
irritation  of  the  peri- 
osteum. This  con- 
tinuous absorption 
and  deposit  accounts 

for  the  hollow,  per-  ^ig.  68.- Cystic  Myeloid  Sarcoma  of  the 
forated    shells    some-  lower  end  of  the  Femur. 

tiTTiPCi         Gjppn  nffAv    «'  Cyst;   6,  medullary  canal  of  the  femur;   c, 

uiiiica         oeen  aiuei        patella:  d,  tibia:  e,  fat  beneath  the  synovial 

TYi n pprfi +.1  An  membrane  of  the  knee-joint;  /,  remains  of 

JUaoerailOn.  ^j^^  femoral  articular  cartilage. 


-\-  a 


444 


Surgical  Pathology.   [Chap.  lxxxix. 


Their  growth  is  slow,  even  when  the  skin  or 
mucous  membrane  has  ulcerated  over  them.  Complete 
removal  often  effects  a  cure ;  very  rarely  do  they  give 
rise  to  secondary  deposits.  They  are  often  cystic, 
seldom  extensively  ossified.  To  the  naked  eye  they 
appear  reddish -brown,  or  ochre -coloured,  or  pale 
yellowish  -  white,  with  splashes  of  a  ruddier  tint. 
Their  uniform  firmness  is  broken  by  patches  of  ossifi- 
cation and  fatty  degeneration,  or  by  cysts  developing, 
or  fully  formed.  When  central  their  outline  is  regular, 
and  they  may  appear  encapsuled  (Fig.  68) ;  when 
springing  from  a  surface  lobulation  is  not  uncommon. 

The  essential  structure  consists  of  large,  round, 
oval,  or  branched  cells,  with  many  nuclei  embedded  in 


Fig,  69. — Myeloid  Epulis  from  Lower  Jaw. 
a.  Multinucleated  giant  cells;  6,  oval  cell,    x  265. 


homogeneous  or  granular  protoplasm.  These  giant 
cells,  which  are  from  -^^  to  joVo  ^^^^^  ^^  diameter, 
are  like  those  of  foetal  marrow,  hence  the  favourite 
situation  of  these  tumours,  and  their  name,  myeloid. 
They  may  be  sparsely  scattered  in  a  bed  of  round  and 
spindle  cells  (Fig.  69).  They  may  constitute  the 
greater  part  of  the  tumour.    When  found  in  peripheral 


Chap.  LXXXIX.]  ThE    SaRCOMATA. 


445 


sarcoma  of  bone,  which,  is  comparatively  rare,  they  do 
not  confer  any  clinical  significance. 

Subvarieties  of  sarcoma. — -1.  Lympho-sarcoTYia,  re- 
sembling the  structure  of  a  lymphatic  gland,  is  really 
a  modification  of  the  round-celled  variety.  There  is 
a  delicate  reticulum,  in  the  meshes  of  vv^hich  the  cells 
are  enclosed  ;  this  is  found  in  the  malignant  lymph- 
adenomata,  and  in  some  sarcomas  of  bone,  especially 
in  children. 

2.  Alveolar  sarcoma  is  chiefly  found  in  bone,  muscle, 
and  skin.    It  seems  to  form  an  anatomical  link  between 


Fig.  70. — Alveolar  Sarcoma  of  Ileum. 

a.  Stroma  composed  of  branched  cells ;  b,  round  nucleated  cells  filling 
alveoli,    x  265. 

sarcoma  and  cancer ;  but  its  affinities,  structural  and 
clinical,  cling  to  the  former.  It  difiers  from  cancer 
(a)  in  that  the  fibres,  which  are  often  only  the  out- 
runners of  cells,  ramify  between  the  individual  cells 
as  well  as  between  the  groups ;  (h)  in  that  the  cells 
are  on  the  connective  tissue  type,  and  are  less  easily 
removed  from  the  stroma  than  in  cancer;  (c)  the  alveolar 
retiform  arrangement  is  more  uniform  (Fig.  70), 


446 


Surgical  Pathology.   [Chap,  lxxxix. 


3.  GlioTiut,  gliosarcoma,  attacks  the  nerve  centres, 
nerves,  and  retina ;  in  the  latter  case  it  is  sometimes 
congenital,  and  it  usually  occurs  in  early  childhood.  It 
is  developed  after  the  manner  of  the  neuroglia  or 
connective  tissue  of  the  nerve  centres.  A  typical  sec- 
tion shows  a  delicate  reticulum  between  the  cells,  but 
often  only  a  scanty  homogeneous  matrix  exists  (Fig. 
71).  The  cells,  mostly  round,  like  lymph  cells,  are 
occasionally  fusiform.    It  is  subject  to  fatty  and  mucoid 


Fig.  71. — Glioma  of  the 
Betina. 

;,  Cells  of  tbe  growtli,  the 
greater  iiumher  of  which  are 
round.  The  rest  are  oat-shaped, 
or  stellate.  The  ir tercel lular 
suhstance  is  faintly  flbrillated. 
6,  blood-vessels.  Their  walls 
are  composed  of  fusiform 
gliomatous  cells,    x  265. 


Fig.  72.—  Glioma  of  tlie  Eetina. 

a,  Sclerotic ;  6,  dislocated  crystalline, 
lens  (it  was  <]uite  transparent^ ;  e, ' 
remains  of  choroid ;  d,  gelatinous 
mass  of  glioma;  e,  patch  of  cheesy- 
lookiiig matter  (fatty  degeneration") ; 
/,  cleft  containing  serous  fluid. 
CNatural  size.) 


degeneration.  When  it  grows  from  the  retina,  the 
fundus  oculi  presents  a  lustrous  bright-yellowish  ap- 
pearance, quite  characteristic.  It  destroys  all  the 
structures,  perforates  the  tunics,  and  forms  a  bleeding 
fungus. 

If  removed  early  it  may  not  return;  but  recur- 
rence in  the  optic  ner^'e  is  to  be  feared. 

4.  Melanotic  sarcoma. — Melanosis  is  more  common 
in  sarcoma  than  cancer,  and  of  the  former  the  spindle- 
celled  variety  is  its  chief  seat.  These  sarcomata  are 
prone  to  occur  where  pigment  is  normally  present ; 
hence  the  choroid,  iris,  and  the  skin  are  the  structures 


Chap.  Lxxxix.]        The  Sarcomata.  447 

usually  aifected  ;  though  they  may  be  found  in  muscle, 
lymphatic  glands,  and  other  tissues. 

The  pigment  is  in  the  form  of  minute  granules. 
It  occupies  chiefly  the  cells ;  probably  that  seen  in  the 
matrix  is  merely  the  remnant  of  disintegrated  cells. 
The  granules  are  black  from  the  first,  and  thus  differ 
from  those  formed  from  extravasated  blood  (Cornil  and 
Eanvier).  The  deposit  commences  around  the  nuclei, 
which  for  some  time  by  their  brightness  contrast 
strongly  with  the  dull,  dark  colour  of  the  pigment. 
The  amount  of  pigmentation  varies  in  different 
tumours,  and  in  different  cells  of  the  same  tumour,  so 
that  to  the  naked  eye  these  growths  appear  grey, 
sepia-coloured,  or  jet  black.  Secondary  growths 
present  the  same  characters.  Melanosis  does  not  add 
to  the  malignancy ;  but  inasmuch  as  these  tumours  are 
mostly  round  or  large  spindle-celled,  the  prognosis  is 
grave. 

5.  Mucous  sarcoma. — With  the  exception  of 
growths  essentially  cystic,  sarcomas  are  more  subject 
to  the  formation  of  cysts  than  any  other  group  of 
tumours.  We  have  said  that  cavities  arising  from 
extravasations  of  blood  and  fatty  degeneration  are 
pathological  accidents ;  but  a  sarcoma  may  be  honey- 
combed by  spaces  filled  with  gelatinous  matter  derived 
from  mucoid  degeneration.  The  coalescence  of  these 
cysts  may  so  hollow  out  the  tumour  that  but  little 
solid  matter  is  left  except  the  septa  and  marginal 
portion,  which  show  the  change  in  progress.  Fresh 
growths  encroaching  upon  these  spaces  project  into 
the  interior,  and  give  rise  to  the  so-called  intracystic 
tumours;  and  by  the  junction  of  papillary  processes 
of  the  latter,  secondary  cysts  are  formed  between 
them.  The  contents  of  the  cysts  are  usually  mucoid, 
but  sometimes  the  fluid  is  clear  and  limpid,  and 
then  perhaps  has  been  derived  from  serous  exudation 
between   the    lobules  and  delicate   capsules  covering 


448  Surgical  Pathology,    chap,  lxxxix 

them ;  and  it  may  be  coloured  with  blood  derived  from 
capillary  rupture.  Cystic  sarcoma  in  the  popliteal 
space  may  easily  be  mistaken  for  an  enlarged  bursa. 

6.  Ossifying  sarcoma. — Osteosarcoma  is  found 
chiefly  in  the  jaws  and  at  the  ends  of  the  long  bones. 
The  bone  may  be  deposited  iii  isolated  patches,  but 
more  commonly  it  occurs  as  a  radiating  outgrowth 
from  the  base  of  the  tumour,  as  in  subperiosteal 
epiphysial  sarcomas,  and  some  epnlides  (Fig.  29).  The 
cells  of  the  tumour  are  converted  into  bone  corpuscles 
with  long  processes.  Haversian  canals  and  canaliculi 
are  constructed,  but  lamellation  is  rare. 

Stibungual  exostoses  occasionally  recur,  and  theii 
may  be  classed  with  the  above.  It  may  be  impossible 
by  the  unaided  eye  to  tell  an  ossifying  from  a  cal- 
cifying sarcoma. 

7.  Chondrosarcoma  by  preference  attacks  the 
ends  of  the  long  bones  and  the  testicles.  The  author 
once  amputated  at  the  hip  joint  for  a  cystic  chondro- 
sarcoma involving  the  whole  length  of  the  shaft  of  the 
femur  ;  it  stopped  short  at  the  level  of  the  epiphysial 
cartilages. 

These  tumours  are  by  some  placed  with  the 
enchondromas,  but  it  is  better  to  name  them  generi- 
cally  from  the  more  malignant  constituent.  Between 
the  nodules  of  cartilage  are  round  and  spindle  cells. 
They  often  ossify  and  calcify. 

When  the  islets  of  sarcoma  cells  are  imbedded  in 
mucous  tissue  the  growth  is  termed  myxosarcoma.. 
Surface  sarcomas,  whether  growing  from  the  skin  or 
into  cavities  {e.g.,  the  maxillary  antrum),  are  habitually 
papillated. 

The  cells  of  a  sarcoma  may  be  filled  with  globules 
of  fat,  not  derived  from  degeneration,  but  from  simple 
infiltration,  lipomatous  sarcoma.  Contrasting  the 
central  with  the  subperiostal  sarcomas  of  bone,  Mr. 
Butlin,  who  has  thoroughly  studied  the  pathology  of 


Chap,  xc]  The  Lymphomata.  449 

these  tumours,  says  the  former  more  often  pulsate, 
do  not  show  a  radiated  structure,  rarely  ossify  or 
chondrify,  are  found  in  older  subjects,  and  are  less 
malignant  than  peripheral  sarcomas,  for  they  have  a 
slower  growth,  and  do  not  infiltrate  the  surrounding 
structures  and  lymphatic  glands  to  the  same  extent. 

Multiplicity  of  groivth  in  sarcomas  may  be  due  : 
(1)  To  a  common  origin,  especially  when  many  bones 
are  affected ;  (2)  to  true  dissemination ;  (3)  to  infil- 
tration of  lymphatic  glands  by  a  continuous  invasion 
from  the  primary  growth. 

The  psanimoiitata. — These  are  small  tumours 
found  in  connection  with  the  membranes  of  the  brain. 
They  are  impregnated  with  calcareous  salts,  hence 
the  name.  In  structure  they  are  composed  of  large 
flat  angular  cells,  arranged  in  concentric  laminae. 
Virchow  describes  them  as  epithelial  conglomerations, 
or  nests,  derived  from  the  cells  lining  the  ependyma 
ventriculorum.  Cornil  and  Ranvier,  who  place  them 
among  the  sarcomas,  have  traced  their  development 
from  vascular  buds  of  the  choroid  plexuses,  and  other 
parts  of  the  pia  mater.  They  explain  the  flattened 
laminated  character  of  the  cells  by  the  pressure  of 
the  blood  in  the  early  stages  of  growth.  If  formed  in 
this  way  they  subsequently  become  isolated  by  oblite- 
ration of  the  vascular  pedicles.  They  are  of  no 
clinical  significance. 


CHAPTER  XC. 

THE    LYMPHADENOMATA. 

The  term  lymphadenoma  or  lymphoma  is  commonly 
applied  to  any  hyperplastic  enlargement  of  a  lym- 
phatic gland,  whether  it  arises  spontaneously,  or  from 

D  D 


450  Surgical  Pathology.  [Chap.  xc. 

simple  irritation.  It  is  difficult  to  separate  the 
two  groups ;  for,  in  the  first  place^  there  is  no 
reason  why  a  peripheral  irritation  of  the  lymphatics 
should  not  excite  the  associated  glands  to  renewed 
developmental  activity ;  and,  again,  hypertrophy  of 
the  gland  may  continue  long  after  the  primary  cause 
has  disappeared,  so  that  one  is  left  in  doubt  as  to  its 
true  nature.  On  the  other  hand,  the  enlargements 
due  to  injury  lead  to  a  typical  end  :  subsidence, 
caseation,  or  suppuration  (the  two  latter  are  pretty 
constant  in  scrofulous  subjects)  ;  whereas  the  non- 
inflammatory lymphomata  tend  to  persist,  and  affect 
other  structures  besides  the  glands. 

The  lymphomata  may  be  arranged  clinically  under 
four  heads:  (1)  The  simple  or  benign  lymphomata; 
(2)  the  malignant  lymphomata,  or  lympho-sarcomata  of 
Yirchow ;  (3)  multiple  lymphomata  of  the  viscera 
{e.g.,  the  liver,  spleen,  kidney,  etc.),  Hodgkin's 
disease,  anaemia  lymphatica,  adenie  (Trosseau) ;  (4) 
the  last-mentioned  group  associated  with  a  marked 
increase  in  the  number  of  white  blood-corpuscles 
(leucaemia,  leucocythsemia). 

(1)  The  benigii  lymphomata.  are  more  nume- 
rous than  the  other  varieties  combined.  They  may  or 
may  not  be  traceable  to  injury  or  precedent  disease. 
Rarely  attaining  a  lai-ge  size,  they  cease  to  grow  after 
a  time,  and  remain  quiescent,  or  shrink  from  fibroid 
condensation.  They  never  extend  beyond  the  glands 
involved,  and  are  consequently  homologous.  They 
are  the  expression  of  tissue  weakness,  but  are  com- 
patible with  good  general  health.  Their  removal  is 
not  attended  with  any  special  danger.  Usually  only 
one  gland  or  group  of  glands  is  affected.  The  neck 
is  the  seat  of  election,  next  to  that  the  groin  and 
axilla. 

General  anatomy. — The  simple  lymphomata  are 
enclosed  within  a  fibrous  capsule,   and  maintain  the 


Chap,  xci  The  Lymphomata.  451 

general  outline  of  the  lymphatic  glands,  being  round, 
oval,  or  kidney-shaped.  They  are  mostly  firm,  some- 
times very  hard,  and  the  consistence  is  fairly  uniform. 
On  section  they  look  greyish  and  semitranslucent,  or 
dull  white  and  opaque,  according  to  the  amount  of 
fibrous  tissue  present.  For  the  same  reasons  they 
are  more  or  less  homogeneous,  or  streaked  with 
whitish  trabeculse. 

Microscopy. — The  ground  substance  looks  glassy 
or  fibrous,  and  forms  meshes  within  which  small  uni- 
nucleated  lymph -cells  are  enclosed.  In  pencilled 
sections  nuclei  may  be  seen  here  and  there  at  the 
nodal  points  of  the  reticulum. 

(2)  The  maligiiaiit  lympUomata  (malignant 
scrofula,  lymphadenomata)  usually  involve  several 
glands,  and  sometimes  several  groups,  cervical, 
mediastinal,  abdominal,  etc.  Clinically  they  are 
sarcomas.  At  first  homologous,  they  may  become 
heterologous  by  invasion  of  surrounding  tissues.  They 
are  often  lobulated  from  adhesion  of  contiguous 
growths.  In  preparations,  the  large  vessels  of  the 
part  are  frequently  seen  to  be  embedded  in  the  mass, 
or  stretched  over  it.  The  elasticity  of  these  tumours 
is  so  great  that  it  may  be  mistaken  for  the  fluctuation 
of  an  abscess.  I  have  seen  them  incised  on  that 
supposition.  Progressive  *  anaemia  complicates  the 
disease,  which  is  fatal  from  asthenia,  or  pressure  upon 
some  vital  organ.  Multiplicity  of  growth  does  not 
imply  dissemination,  as  in  carcinoma;  it  is  the  sign  of 
wide-spread  instability  of  tissue  in  the  lymphatic  gland 
system.  If  left  alone  it  is  quite  the  exception  for 
these  tumours  to  fungate,  but  if  incised  they  pursue 
an  intractable  course.  Attempts  at  removal  are 
often  futile,  and  certainly  dangerous,  for  during 
the  operation  the  disease  is  rarely  found  to  be  as 
limited  as  appeared  from  a  surface  examination ;  and 
the  deep  dissections  required  may  lead  to  cellulitis 


452  Surgical  Pathology.  [Chap.  xc. 

aud  pyaemia ;  besides,  the  patients  are  bad  subjects 
for  the  repair  of  extensive  injuries. 

General  anatomy. — The  mass  is  bounded  by  a  thin 
capsule,  or,  more  rarely,  it  is  infiltrating.  In  the 
latter  case  the  original  capsule  of  the  gland  has 
disappeared  before  the  ravages  of  the  disease,  or  else 
the  growth  has  started  in  some  part  other  than  a 
lymphatic  gland;  e.g.,  the  upper  jaw.  The  cut 
surface  appears  grey  or  yellowdsh-gTey  throughout,  or 
it  is  mottled  and  flecked  with  red  from  capillary 
extravasation.  Patches  of  softening  and  caseation 
may  be  seen.  The  distinction  between  the  medullary 
and  cortical  portions  of  the  gland  disappears. 

Microscopy. — Small  lymph  cells  form  the  greater 
part  of  the  tumour ;  but  there  are  also  large  multi- 
nucleated cells  which  indicate  rapid  growth,  the 
nuclei  having  divdded  more  quickly  than  the  proto- 
plasm. The  stroma  is  very  delicate  ;  to  see  it  the 
specimen  must  be  shaken  in  water  or  lightly  brushed. 
It  is  largely  made  up  of  branched  cells. 

(3)  l<ymplioiiiata  of  tlie  viscera  aud  other 
stractures  are  met  with  in  the  spleen,  liver,  kidneys, 
stomach,  intestines,  tonsils,  and  thymus  gland.  The 
lymphatic  glands  are  usually  involved  at  the  same 
time.  The  liver  and  spleen  attain  a  great  magnitude; 
in  one  case  the  former  weighed  seven,  and  the  latter 
eight  pounds.  The  gi'owth  consists  of  an  aggi-egation 
of  nodules  from  the  size  of  a  pin's  head  to  a  marble. 
In  the  spleen  it  affects  chiefly  the  Malpighian 
glomeruli ;  in  the  liver,  the  interacinose  tissue  (JFig.  73) ; 
in  the  stomach,  the  solitary  glands ;  in  the  intestine, 
Peyer's  patches  and  the  solitary  glands.  I  have  seen 
a  lymphoma  of  the  thymus  as  large  as  a  cocoanut. 

The  minute  structure  is  much  the  same  as  described 
in  the  other  forms;  indeed,  it  may  be  said  of  all  lym- 
phomata  that  they  are  reproductions  with  variations  of 
tlie  adenoid  tissue  of  His  :  in  some  there  is  scarcely 


Chap.  XC] 


Le  UCOCYTH^MIA  . 


453 


any  departure  from  the  normal,  in  others  the  fibrous 
or  the  cellular  element  predominates,  or  the  growth  is 
modified  by  secondary  nutritive  changes.  This  adenoid 
tissue  has  a  wide  natural  distribution,  for  apart  from 
the  structures  of  which  it  is  the  chief  constituent,  it 
is  met  with  in  the  liver,  walls  of  the  alimentary  canal, 


Fig.  73. — LymplLOina  of  Liver  from  a  case  of  Leucocytlisemia. 

a.  Liver-cells ;  6,  adenoid  tissue,  showing  nodal  enlargements  of  tlie  mesliwork. 
Most  of  tlie  lymph-cells  have  heen  removed,    x  265. 


around  the  bronchioles  and  arterioles  of  the  lung,  and 
the  vessels  of  the  nerve  centres,  and  lastly  in  bone. 
The  extensive  range  of  distribution  of  the  lymphomata 
as  homologous  growths  is  thus  easily  explained. 

L.eiicocytliseiiiia. — In  this  disease  there  is  a 
great  increase  in  the  number  of  white  blood-corpuscles. 
It  is  associated  with  lymphoma  of  the  spleen,  or 
lymphatic  glands,  or  both.  Its  etiology  is  obscure,  for, 
as  before  said,  the  preceding  group  may  exist  without 
it.  Again,  it  cannot  be  said  that  a  morbidly  in- 
creased formative  activity  of  the  lymphatic  glandular 
system  leads  to  an  increased  functional  activity. 
During  the  course  of  the  disease  diffuse  haemorrhages 
may  occur.  This  has  to  be  borne  in  mind,  to  avoid 
mistaking  the  extravasations  for  abscesses  of  the  sub- 
cutaneous, submucous^  and  intermuscular  tissue. 


454  Surgical  Pathology.  [Chap.  xci. 

The  Lymphangiomata. 

Swellings  consisting  largely  of  distended  lym- 
phatics liave  been  observed  in  the  tongue  (one  form 
of  hypertrophy  of  that  organ),  lips,  cheek,  and 
subcutaneous  tissue  of  the  abdomen,  thigh,  and 
genital  organs.  In  some  cases  the  dilatation  and  vari- 
cosity of  the  lymphatics  have  been  traced  into  the 
neighbouring  glands  (adeno-lymphocele;  Nelaton). 
In  elephantiasis  of  the  Arabs  the  new-formed  tissue 
contains  numerous  large  lymph  spaces  filled  with  clear 
fluid  :  and  this  disease  is  known  to  be  preceded  and 
accompanied  at  intervals  by  lymphatitis,  but  whether 
there  is  any  new  formation  of  lymphatics  is  not 
certain.  On  anatomical  grounds  there  is  no  reason 
why  there  should  not  be  a  new  development  in  con- 
nection with  the  lymphatic,  as  well  as  with  the  blood 
vascular  system. 

The  swellings  above  referred  to  are  termed  "caver- 
nous lymphatic  tumours,"  or  lymphatic  nsevi.  They 
form  soft,  doughy,  or  fluctuant  masses,  and  occasionally 
exude  lymph  on  the  surface  (lymphorrhsea). 


CHAPTER   XCI. 

THE    PAPILLOMATA. 

The  epithelium  of  the  skin  and  mucous  membranes, 
instead  of  forming  a  plane  surface,  is  usually  raised 
into  papillary  or  rugose  elevations,  or  involuted  as 
sweat,  sebaceous,  or  mucous  glands.  This  disposition 
constitutes  the  basis  of  the  papillomata  and  adenomata 
respectively.  The  new  growth  is  hot  composed  entirely 
of  epithelium,  for  there  is  hypertrophy  of  the  j^roper 
cutaneous  and  mucous  tissues. 


Chap,  xci.]  The  Papillomata,  455 

The  cutaneous  papillomata  comprise  warts 
(hard  and  soft),  corns,  and  horny  excrescences. 

Warts  are  hypertrophic  enlargements  of  the 
papillae  of  the  skin.  In  many  cases  they  spring  up 
spi.aitaneouslT,  hut  in  others  there  is  some  precedent 
irritation.  The  former  have  a  peculiar  tendency  to 
appear  on  the  face  and  hands,  especially  in  children ; 
whilst  the  latter  are  prone  to  alfect  the  skin  at  its 
junction  with  the  mucous  membrane,  notably  about  the 
genital  parts.  Gonorrhceal  vKtrts  on  the  penis  and 
vulvse  are  caused  by  friction  combined  with  the 
ii'ritation  from  acrid  discharges.  They  are  inflamma- 
tory, to  begin  with,  but  they  are  classed  with  the 
papillomata  on  account  of  their  structural  identity, 
and  because  they  often  continue  to  grow  long  after  the 
primary  cause  has  been  removed.  They  differ  from 
syjjhilitic  mucous  tubercles  in  that  they  rarely  dis- 
appear spontaneously.  They  are  usually  multiple. 
When  large  they  are  known  as  cauliflower  excrescences. 

Warts  on  the  general  surface  are  either  soft  or 
hard.  In  each  case  there  is  overgrowth  of  the 
papillary  and  epidermal  layers.  The  difference  in 
density  depends  upon  the  amount  of  epithelium  and 
its  degree  of  cornification.  The  soft  variety  is 
smoother  than  the  hard,  and  is  more  often  pigmented, 
and  it  has  a  greater  tendency  to  affect  persons 
advanced  in  age.  Cutaneous  warts  consist  simply  of 
a  group  of  enlarged  papillse,  or  the  latter  branched 
from  division  and  subdivision. 

Corns  are  met  with  where  the  skin  is  subjected  to 
intermittent  pressure .  The  horny  layer  of  the  epidermis 
is  very  thick  and  dense,  and  not  only  covers  the 
individual  papillee,  but  fills  up  the  hollows  between 
them,  so  that  the  surface  is  more  or  less  sm.ooth. 

Horny  excrescences  are  sometimes  more  than  an 
inch  in  length.  The  hard  epidermal  cells  are  so 
firmly  welded  that  there  is  little  or  no  desquamation. 


45^ 


Surgical  Pathology. 


[Chap.  xci. 


Tliey  start  either  from  tlie  surface,  or  in  the  hair 
folHcles  and  sebaceous  glands.  They  have  been  found 
in  dermoid  ovarian  cysts. 

Mucous  papillomata  occur  on  all  the  mucous 
membranes,  but  they  are  more  frequent  where  papilhe 


Fig.  74— Simple  Villous  Tumour  of  the  Bladder. 
a.  Columnar  epithelial  cells ;  6,  large  capillary  blood-vessels,    x  265. 

normally  exist;  e.g.^  in  the  tongue.  Tliey  are  more 
succulent  than  the  cutaneous  gro^i:hs,  and  their  den- 
sity varies  as  the  kind  of  epithelium.  Thus,  in  the 
tongue,  where  it  is  squamous  and  stratified,  they  are 
firmer  than  in  the  bladder  and  rectum. 

In  the  bladder  in  particular  they  form  soft  villous 


Chap,  xci.]  The  Papillomata.  457 

growths,  with  long  processes,  simple  or  branched  ;  and 
here  their  vascularity  is  so  great,  and  the  vessels  so 
little  supported  by  the  surface  epitheKum,  that  pro- 
fuse bleeding  is  not  a  rare  event.  Vesical  papillomata 
are  mostly  seen  near  the  orifices  of  the  ureters,  but  the 
entire  mucous  membrane  may  be  converted  into  a 
shaggy  flocculent  coating.  The  epithelium  is  squamous 
or  columnar,  and  disposed  in  a  single  layer,  or  strati- 
fied (Fig.  74).  In  the  rectum  it  is  columnar.  Papil- 
loma of  the  larynx  is  nearly  six  times  as  common  as 
epithelioma.  It  is  usually  seated  on'  or  near  the 
vocal  cords. 

Papillomata  of  the  serous  memforaiies. — 
Some  authors  include  hypertrophy  of  the  synovial 
articular  fringes  in  the  papillomatous  gi'oup.  They 
have  been  described  in  the  chapter  on  joint  diseases 
(Fig.  39). 

Papillary  forms  of  other  §tot^1is. — Most 
of  the  new  formations  arising  from  the  skin  and 
mucous  membranes  are  prone  to  assume  a  papillary 
surface  outline.  This  is  very  marked  in  the  malignant 
tumours,  and  especially  in  epithelioma ;  in  fact,  it  is 
dij9S.cult  in  some  cases  to  say  with  certainty  whether  a 
warty  growth  in  its  early  stage  is  a  papilloma  or  a 
papillary  epithelioma.  And,  again,  a  papilloma  may, 
by  continued  irritation,  take  on  a  cancerous  nature. 

From  a  mere  surface  view,  it  is  impossible  to  tell  a 
villous  tumour  of  the  bladder  from  a  villous  cancer ; 
but  the  former  grows  entirely  from  the  surface, 
v/hereas  the  latter  invades  and  infiltrates  the  entire 
thickness  of  the  walls. 

Sarcomas  of  the  nasal  fossa,  antrum,  and  other 
cranial  sinuses  are  often  papillated.  The  intracystic 
formations  of  many  ovarian  tumours  are  foliated. 

General  anatomy  and  histology — Where 
papillae  enter  into  the  normal  structure  of  the  part, 
the  type    is    simply   maintained  in  the  new  growth. 


458  Surgical  Pathology.         [Chap. xcii. 

Tlius,  in  a  wart  tlie  cutaneous  papillae  are  reproduced, 
though  in  a  disorderly  form ;  the  basis  of  the  tumour 
is  made  up  of  connective  tissue  rich  in  corpuscles ;  the 
vessels  are  plexif orm  or  looped ;  the  epithelium  on  the 
surface  is  more  or  less  columnar  below,  squamous  and 
stratified  above ;  its  extent,  degree  of  conification,  and 
disposition  vary  in  different  cases,  but  it  is  always 
homologous.  In  epithelioma  it  is  homologous  at  first, 
but  afterwards  essentially  heterologous. 

In  mucous  membranes  devoid  of  papillse  the  out- 
line of  the  tumour  can  be  explained  by  the  looped 
arrangement  of  the  vessels  and  the  centrifugal  direc- 
tion of  the  vascular  pressure,  as  in  the  granulations  of 
an  ulcer. 

Under  the  microscope,  transverse  sections  of  the  tips 
of  the  papillae  look  very  like  the  nescs  of  epithelioma. 

Secondary  ctiang-es.  —  These  are  ulceration, 
haemorrhage  (surface  and  interstitial),  pigmentation, 
epitheliomatous  degeneration,  and,  in  some  cases, 
atrophy  and  complete  obliteration. 

Ulceration  and  h£emorrhao;e  are  rare  in  the  cuta- 
neous  papillomata ;  far  from  it  in  the  mucous,  which 
are  ill  protected  from  friction  and  other  sources  of 
irritation.  This  is  markedly  the  case  with  villous 
tumour  of  the  bladder. 

Pigmentation  is  almost  confined  to  papilloma  of 
the  skin. 


CHAPTER   XCII. 

ADENOID    TUMOURS. 


Any  new  growth,  simple  or  malignant,  arising 
from  glandular  tissue  has  a  tendency  to  assume  the 
adenoid  type.  Adenoid  tumours  may  be  conveniently 
divided  into  five  groups  : 


Chap.  XCII.] 


Adenoid  Tumours. 


459 


(1)  Malignant  tumours,  e.g.,  columnar  epitbelioma 
of  the  rectum  {yicle  Fig.  59),  and  its  secondary  lesions 
in  the  liver,  also  the  acinous  variety  of  scirrhous 
cancer  of  the  breast.  They  are  none  the  less 
malignant  because  stamped  with  the  physiological 
likeness  of  the  part  affected. 

{2)  Hypertrophies  of  the  thyroid,  mammary,  and 
prostate  glands.  In  each  there  is  considerable  repro- 
duction of  glandular  tissue.  Their  right  to  be  classed 
with  the    adenoid   growths  is  further  shown  by  the 


Fig.  75. — Fibro-glandnlar  Polypus  from  the  Eectnm  of  a  Child. 

a.  Acinus  lined  with  columnar  epithelium  ;  5,  flhro-nucleated  stroma  ;  c,  hlood- 

Yessel.    X  265. 


fact  that  encapsuled  masses,  containing  loculi  with 
regularly  disposed  epithelium,  are  also  met  with  in 
these  organs,  either  alone  or  in  conjunction  with  the 
more  diffused  enlargement. 

These  are  the  cases  that  prove  how  difficult  it 
sometimes  is  to  distinguish  between  hypertrophy  and 
tumour  when  no  physiological  reason  can  be  assigned 
for  the  overgrowth,  and  when  the  microscopical 
characters  are  practically  the  same. 

(3)  Certain  benign  pedunculated  tumours  attached 
to  the  mucous  surfaces,  e.g.,  glandular  polypus  of  the 


460  Surgical  Pathology.        rchap.  xcii. 

rectum.  {J^ide  Fig.  75.)  In  these  the  epithelial 
adenoid  tissue  forms  acini,  even  in  the  deeper  portions 
of  the  grovvth.  This  must  not  be  confounded  with 
simple  involutions  of  the  surface  epithelium  occasionally 
present  in  many  polypi,  e.p'.,  mucous  polypus  of  the 
nose. 

(4)  The  important  group  of  tumours  termed 
adenomata,  or  adenoceles,  of  which  the  best  instance 
is  seen  in  the  breast. 

(5)  The  lymphadenomata,  which  consist  of  tissue 
resembling  that  of  a  lymphatic  gland. 

Adenoma,  or  adeiiocele  of  tlie  breast. — 
"  Chronic  mammary  tumour  "  is  met  with  at  different 
ages^  but  chiefly  in  early  and  mid-adult  life.  It  is 
either  embedded  in.  the  gland  or  attached  to  the 
surface.  In  either  case  it  is  distinctly  encapsuled, 
and,  as  a  rule,  freely  movable  apart  from  the  breast. 

It  does  not  infect  the  lymphatic  glands  or  internal 
organs.  It  neither  causes  retraction  of  the  nipple 
nor  puckering  of  the  skin.  Ulceration  is  very  rare, 
and  this  only  happens  when,  by  the  size  of  the  tumour, 
the  skin  has  become  atrophied  by  pressure,  and  ex- 
posed to  injury.  It  is  often  lobulated.  The  density 
varies  according  to  the  amount  of  fibrous  tissue 
present  in  the  growth ;  it  may  be  so  hard  as  to 
simulate  scirrhus.  The  size  usually  ranges  from  that 
of  a  marble  to  an  orange,  but  there  is  no  certainty. 
I  have  examined  a  specimen  that  weighed  eight 
pounds.  Unlike  sciiThus,  it  does  not  cup  on  section, 
for  the  tension  is  fairly  uniform  throughout.  The 
lobulation  of  the  surface  is  continued  into  the  interior ; 
it  may  be  scarcely  visible,  or  so  decided  that  the  lobules 
appear  partitioned  off  by  fibrous  dissepiments;  it 
becomes  more  manifest  on  tearing  away  portions  of 
the  growth,  for  then  the  lobules  '•'  shell  out."  The 
lobules  maybe  so  small  as  to  make  the  sui'face  merely 
granular,  or  so  large  as  to  exceed  ii  walnut  in  si^e. 


Chap,  xcii.]    Adenoma  of  the  Breast. 


461 


Scraping  does  not  yield  a  milky  juice,  but  a  slightly 
turbid  fluid,  and  coarse  particles  composed  of  cells  and 
fibres,  and  often  minute  gland-buds.  Fibrous  tissue 
almost  invariably  exceeds  in  amount  the  glandular 
element.  This  has  led  to  the  designation  fibro- 
adenoma. 

Microscopy. — The    glandular    sjoaces    show    great 
diversity  of  outline,  being  round,  oval,  or  sinuous.      In 


Fig.  76. — Adenoma  of  the  Breast. 

a,  Group  of  glandular  acini ;  b,  fibrous  stroma ;  c,  cells  loroken  away  from 
tbeir  attachment,    x  265. 


extent,  too,  they  vary  much,  being  wide,  like  open 
ducts,  or  mere  chinks  in  the  fibrous  stroma.  Their 
interior  is  lined  by  columnar  or  cubical  epithelium, 
usually  in  one  layer,  but  sometimes  the  cells  are  two 
or  three  deep  (Fig.  76).  The  central  portion  of  each 
space  appears  clear,  or  granular  from  epithelial  debris. 
There  is  a  much  closer  resemblance  to  healthy 
gland  tissue  than  in  the  alveoli  of  scirrhous  cancer. 
The  stroma  is  in  most  cases  very  dense,  and  its  cells 
sparsely  scattered,  but  in  some  it  is  succulent  and 
richly    corpuscular.       In    a  series   of   cases  one  may 


462  Surgical  Pathology.         [Chap.  xcii. 

notice  a  gradual  declension  from  a  firm  hard  nodule 
of  adeno-fibroma  to  a  soft,  rapidly  enlarging  adeno- 
sarcoma. 

Cysts,  which  are  by  no  means  rare,  arise  for  the 
most  part  from  dilatation  of  the  gland  spaces  ;  but  some 
seem  to  be  connected  in  their  origin  with  the  lym- 
phatics, for  I  have  found  both  cubical  and  pavement 
epithelium  lining  the  interior.  The  fluid  in  the  cysts 
is  clear  and  mucoid,  or  opaque  from  admixture  with 
blood,  and  then  it  may  have  a  reddish-  chocolate  or 
sepia-like  tint,  according  to  the  amount  and  age  of 
the  extravasation.  In  such  cases  any  discoloration 
of  the  cyst  wall  and  tissue  around  must  not  be 
mistaken  for  true  pigmentation. 

Now  and  then  a  considerable  portion,  or  even  the 
whole  of  the  breast,  is  found  to  be  enlarged  and 
nodular  on  the  surface,  without  any  distinct  capsular 
limitation  to  the  growth.  This  has  been  termed 
"  diffuse  adenoma,''^  or  hypertrophy. 

Adenoma  of  tlie  parotid  is  met  with,  in  which 
the  structure  is  entirely  glandular,  or  fibro-glandular ; 
but  it  is  more  often  combined  with  mucous,  car- 
tilaginous, or  embryonic  tissue,  one  or  more  of  them. 
There  are  two  varieties  of  adenoma,  tubular  and 
acinous.  As  in  the  case  of  the  breast,  it  may  be 
seated  deeply  in  the  gland,  or  loosely  attached  to 
the  surface.  In  either  case  it  starts  beneath  the 
capsule  of  the  gland,  though  in  its  subsequent  growth 
this  may  become  so  thinned  as  to  be  scarcely 
recognised,  and  this  has  led  to  the  idea  of  the  tumour 
being  extracapsular  from  the  beginning. 

The  submaxillary  and  sublingual  glands  are  much 
less  frequently  aflected. 

Adenoma  of  the  prostate  is  rarely  met  with 
as  constituting  the  entire  disease.  Usually  it  forms 
part  of  a  more  general  enlargement  or  hypertrophy. 
Koundish    masses,  enclosed   in  more  or  less  distinct 


Chap. XGiL]  The  Adenomata.  463 

capsules,  project  as  pedunculated  tumours  into  the 
bladder,  or  lie  embedded  in  the  substance  of  the 
gland.  In  the  latter  case  they  can  sometimes  be 
readily  enucleated.  The  nodule  from  which  Fig.  57 
was  taken  was  removed  during  the  operation  of 
lithotomy.  It  formed  a  bar  to  the  passage  of  the 
stone,  and  was  displaced  by  the  forceps.  It  will  be 
seen  to  consist  of  glandular  and  muscular  elements 
in  a  nucleated  fibrous  stroma.  The  epithelium  is 
columnar,  as  in  the  mucous  glands  of  the  prostate. 

The  adenomata  are  perfectly  benign,  and  the 
epithelial  cells  are  homologous  throughout.  This  at 
once  distinguishes  them  from  the  carcinomata,  where 
the  epithelium,  though  at  first  homologous,  sub- 
sequently becomes  heterologous,  ^.e.,  it  is  found 
invading  tissues  from  which  it  is  normally  absent. 
In  the  earlier  stages  of  development  it  is  very  difficult 
to  tell  an  adenoma  from  a  cancer  growing  from  the 
same  part,  for  in  each  the  epithelium  is  at  first 
confined  to  the  ducts  and  acini  of  the  gland. 

Adenoma  has  been  described  in  almost  all  the 
situations  where  gland  tissue  normally  exists.  We 
suspect  that  secondary  epithelioma  of  the  liver  has 
been  mistaken  for  adenoma.  It  is  next  to  impossible 
to  differentiate  the  two  by  the  microscopical  characters  ; 
and  if  there  be  only  a  single  nodule  the  difficulty  is 
increased,  especially  if  its  growth  be  slow,  and  it 
possess  an  adventitious  capsule  from  irritative  over- 
growth of  the  hepatic  interstitial  tissue. 


464 


CHAPTER    XCril. 

CYSTS. 

The  classification  of  cysts  can  be  made  on  several 
bases  :  (1)  Their  origin ;  (2)  their  contents ;  (3)  the 
organs  and  tissues  affected.  The  first  is  followed  in 
this  work ;  it  is  a  modification  of  the  system  adopted 
by  E.  Wagner. 

1.  Cysts  derived  from  the  distention  of  natural 
cavities. 

{a)  Cysts  that  have  their  origin  in  closed  spaces. 

(a)  Serous  cysts,  e.g.,  enlarged  bursse,  ganglia 
on  the  sheaths  of  tendons,  spinal  and 
cerebral  meningoceles,  and  vaginal  and 
funicular  hydroceles. 

()8)  Cysts    formed    by    hypersecretion    in 
closed  follicles,  e.g.,  some  ovarian  cysts 
and  cystic  goitre. 
(6)  Retention   cysts,   from   partial    or   complete 

obliteration  of  ducts  or  orifices  of  glands. 

(«)  Sebaceous  or  atheromatous  cysts. 

(iS)  Mucous  cysts,  e.g.,  ranula. 

(7)  Those  containing  a  more  specific  secre- 
tion, e.g.,  salivary  cysts,  dropsy  of  the 
gall  bladder,  hydronephrosis,  and  renal 
cysts. 
(c)  Cysts    arising    from   the    dilatation   of   ob- 
structed blood-vessels  and  lymphatics. 

2.  Parenchymatous  cysts,  or  those  of  independent 
origin. 

(a)  Cysts  derived  from  the  dilatation  and  fusion 
of  connective  tissue  spaces,  such  as  bursse 
formed  beneath  the  skin  in   club-foot  and 


Chap.  XCIII.]  CVSTS.  465 

corns  ;  also  congenital  tumours  of  the  neck 
and  hydrocele  of  the  neck. 
(5)  Adventitious  cysts,  whose  walls  are  con- 
stituted by  the  condensation  of  the  con- 
nective tissue  of  the  part.  They  are  formed 
around  parasites,  hydatid  tumours,  blood 
clots,  etc. 

(c)  Cysts  of  congenital  origin,  chiefly  found  in 

the  ovary.  They  are  called  dermoid  cysts, 
since  their  contents  are  made  up  for  the 
most  part  of  cutaneous  and  epidermal  ele- 
ments, glands,  hair,  teeth,  etc. 

(d)  Cystic  new  formations,  very  common  in  sar- 

coma,   enchondroma,    and    other    growths. 
( Vide  Fig,  5.) 
3.  Extravasation  cysts. 

(a)  From  effusion  of  blood  into  pre-existing 

sacs  (hgematocele). 
{&)  From   diffuse    extravasation  into   solid 
tissues,  especially  the  new  growths ;  and 
into  the  brain. 
Serous  cysts. — (1)  Enlarged  bursce  are  usually 
of  inflammatory  origin.     The  term  hygroma^  which  is 
usually  applied  to  them,  is  by  some  pathologists  ex- 
tended to  all  serous  and  mucous  cysts.    The  most  impor- 
tant are  those  situated  in  front  of  the  patella,  on  the 
inner  side  of  the  knee  and  over  the  ischial  tuberosities 
(in  tailors)  and  great  trochanters.      The  walls,  which 
are   composed  of  fibrous  tissue,  are  sometimes  quite 
thin  ;  at  others  thick  and  rugged.     The  cavity  may 
be  a  mere  chink  or  as  large  as  a  double  fist. 

The  inner  surface  of  the  cyst  is  lined  by  flat 
epithelium,  though  this  often  becomes  destroyed. 
The  contents  are  clear  and  serous  or  mucous,  or  tur- 
bid from  admixture  with  blood  and  the  fatty  debris 
of  inflammatory  products.  In  one  case  I  extracted 
half  an  ounce  of  cholesterine  from  a  single  enlarged 
E  E 


466  Surgical  Pathology.        [Chap,  xciii. 

pre -patellar  bursa.  Sometimes  they  contain  loose 
bodies,  resembling  those  found  in  ganglia  and  arti- 
cular synovial  membranes. 

(2)  Ganglia  are  simple  and  compound.  They  are 
most  common  about  the  wrists  and  ankles.  The 
compound  ganglia  are  irregular  dilatations  of  the 
sheaths  around  groups  of  tendons,  e.g.^  the  flexors  of 
the  fingers.  Simple  ganglia  are  pouch-like  dilatations 
that  have  become  shut  off  from  the  synovial  sheaths. 
The  contents  of  ganglia  are  usually  clear  and  viscid. 
The  compound  variety  often  contains  loose  bodies, 
some  of  which  appear  to  be  fibrinous  exudations 
concentrically  laminated,  but  the  majority  are  hyper- 
trophied  buds  or  fringes  detached  from  the  cyst  wall. 

Closed  follicular  tiypersecretioii  cysts. — 
(1)  Simple  ovarian  cysts,  not  rare  in  children.  They 
arise  from  distention  of  Graafian  follicles,  and  do  not 
j)roliferate  like  the  compound  cysts  of  the  ovary. 

(2)  Cystic  hroncliocele. — The  glandular  acini  of 
the  thyroid  body  first  become  choked  with  epithelium  ; 
this  undergoes  colloid  softening,  which  extends  to  the 
trabeculse.  The  stroma  is  partly  destroyed  by  atrophy 
from  the  pressure  of  the  fluid  within.  Thyroid  cysts 
are  single,  or  multiple  and  loculated  ;  they  may  be 
larger  than  an  orange.  Their  contents  are  viscid  and 
yellow,  or  thin  and  either  clear  or  turbid.  {Vide 
Colloid  degeneration.) 

Retention  cysts. — 1.  Sebaceous  cysts. — This 
group  includes  molluscum  contagiosum,  strophulous 
albidus,  comedones,  and  the  ordinary  form  of  sebaceous 
cyst. 

(a)  Mollusciiifn  contagiosum. — This  consists  of 
small  tumours  looking  like  "drops  of  white  wax" 
(T.  Fox).  They  are  seated  for  the  most  part  on  the 
face,  neck,  trunk,  and  arms.  They  vary  from  the 
size  of  a  pin's  head  to  that  of  a  marble.  They  are 
umbilicated  in  the  centre,  the  depression  marking  the 


Chap,  xciii.]  Cysts.  467 

site  of  the  obstructed  duct.  Thej  are  sessile,  or 
broadly  pedunculated.  The  nature  of  the  contagious- 
ness is  uncertain.  Fox  says  it  is  not  parasitic.  The 
cells  go  through  the  ordinary  evolution  of  sebaceous 
secretion, 

{h)  Comedones  are  small  hard  elevations  caused 
by  distention  of  the  sebaceous  glands.  Their  apices 
present  black  specks  from  accumulation  of  dirt. 
When  indurated  from  irritation  we  have  acne  punctata. 

(c)  Stroj^hulus  albidus  of  children  is  similar  to  the 
last.  It  has  the  appearance  of  millet  grains.  The 
obstruction  of  the  gland  orifice  is  due  to  the  irritation 
of  heat  and  moisture. 

{d)  Sebaceous  cysts  proper — atheromatous  cysts 
are  found  chiefly  in  the  scalp,  but  all  parts  of  the  skin 
are  subject  to  them. 

In  the  scalp  they  are  rarely  larger  than  a  walnut, 
but  in  other  parts  (the  back,  e.g.)  they  sometimes 
exceed  the  size  of  a  large  orange.  There  is  usually 
obliteration  of  the  glandular  orifice.  The  skin 
becomes  stretched  over  the  tumour,  and  its  dis- 
tinctive structure  modified  by  atrophy  from  pres- 
sure or  hypertrophy  from  fiiction.  As  the  cyst 
enlarges  it  occupies  the  subcutaneous  tissue,  and  it 
may  then  be  mistaken  for  chronic  abscess  or  a  soft 
fatty  tumour.  The  cyst  wall  is  made  up  of  parallel 
layers  of  connective  tissue.  The  contents  may  be  soft 
like  honey  (melicerous  cysts) ;  fluid  when  it  is  clear 
or  chocolate  or  sepia-like  from  fat  and  blood  pigment; 
or  quite  firm  (cholesteatoma) ;  under  the  microscope 
fat  granules,  epithelial  cells,  cholesterine,  and  fat 
crystals  can  be  recognised  in  varying  proportions. 
The  epithelium  lining  the  cyst  is  stratified.  The  cells 
next  the  cyst  wall  have  large  nuclei,  and  show  signs  of 
proliferation;  farther  in  they  are  of  the  ordinary  pave- 
ment variety,  whilst  those  abutting  on  the  cavity 
are    filled    with    fat    and    devoid    of    nuclei.       This 


468  Surgical  Pathology.        [Chap,  xciii. 

epithelial  lining  is  sometimes  of  horny  consistence,  the 
cells  being  welded  together  so  that  the  entire  lamina 
can  be  shelled  out.  The  cysts  sometimes  rapture 
and  give  rise  to  inveterate  ulcers  that  may  be  mistaken 
for  epithelioma.  This  is  due  to  the  persistence  of  the 
secreting  epithelium  in  the  interior  of  the  cysts, 
hence  in  operating  upon  the  latter  care  should  be 
taken  to  remove  the  whole  of  the  secreting  surface. 
Sebaceous  cysts  are  by  some  spoken  of  as  wens,  a  term 
also  applied  to  a  variety  of  fibroma  (page  411). 

2.  Mucous  cysts. — These  are  met  with  in  the  lips 
and  buccal  mucous  membrane.  They  are  not  un- 
common in  the  floor  of  the  mouth,  where  they  consti- 
tute one  form  of  ranula  (others  are  derived  from 
obstruction  of  the  salivary  ducts  and  from  free  cyst 
formation,  and  the  contents  vary  accordingly). 
Labial  and  buccal  mucous  cysts  look  transparent, 
and  contain  a  viscid  secretion.  Cysts  of  like  nature 
are  seen  in  the  stomach,  intestine,  trachea  and  uterus. 

3.  Cysts  containing  specific  secretion. — Amongst 
these  are  salivary  cysts,  the  cause  of  which  is  inflam- 
mation about  the  ducts,  or  impaction  of  a  calculus. 
Hepatic  cysts  contain  the  constituents  of  bile.  They 
arise  in  one  of  two  ways,  either  from  obstruction  of 
the  small  biliary  ducts,  or  thrombosis  of  the  sublobular 
Veins.     Their  contents  are  often  putty -like. 

Renal  cysts  involve  the  entire  cortex,  so  that 
the  organ  looks  something  like  a  bunch  of  grapes ;  or 
they  are  isolated  and  scattered.  The  former,  which 
may  be  congenital,  are  essential  cystic  formations  ;  the 
latter  are  more  or  less  accidental,  and  are  found 
associated  with  other  morbid  conditions,  especially 
gouty  kidney ;  they  are  the  result  of  obstruction  of 
the  tubules,  and  the  wall  of  the  cysts  is  usually  a 
distended  Malpighian  capsule.  These  retention  cysts 
may  contain  urates  (Yirchow),  and  urea  (Cornil  and 
Ranvier). 


Chap.  XCiri.]  CVSTS.  469 

Cysts  arismg  from  tlic  dilatation  of  ob- 
structed blood-vessels  and  lymphatics  are  not 

very  common.  In  the  case  of  the  blood-vessels  the 
circulation  is  arrested,  thrombosis  follows,  and  the 
clot  undergoes  liquefaction.  The  wall  of  the  vessel 
becomes  much  altered,  and  the  cyst  enlarges  by  the 
exudation   of  serum. 

Lymphatic  cysts  are  lined  by  a  tesselated  epi- 
thelium, and  their  contents  are  clear  from  the  first. 

ParencliymatOMS  cysts. —  1 .  Mucous  burscB 
are  developed  where  there  is  intermittent  pressure. 
Embryonic  is  converted  into  mucous  tissue,  and  the 
cells  and  fibres  of  the  latter  undergo  mucoid  lique- 
faction. The  external  cells  remain  as  an  endothelial 
lining  to  the  cysts. 

Congenital  cystic  tumours  of  the  neck  often  attain 
a  large  size.  The  solid  portion  of  the  growth  may 
predominate  over  the  cystic  ;  there  is  great  variation 
in  this  respect.  The  cysts  form  in  embryonic  tissue, 
the  cells  of  which  become  distended  with  m-ucin  and 
then  disappear.  Hydrocele  of  the  neck  is  a  serous  cyst. 
It  may  be  likened  to  the  subcutaneous  bursse,  though 
no  cause  may  be  assigned  for  its  development.  I  once 
saw  one  as  large  as  an  ostrich's  egg ;  it  was  translucent, 
and  was  filled  with  limpid  fluid;  it  was  surrounded 
by  loose  areolar  tissue,  and  the  wall,  which  was  very 
thin,  had  an  exquisite  mosaic  of  pavement  epithelium 
on  the  inner  surface. 

2.  Adventitious  cysts  require  no  further  description 
than  is  given  in  the  table. 

3.  Dermoid  cysts  are  met  with  chiefly  in  the 
ovary.  They  are  usually  congenital.  Their  cavities 
are  single  or  loculated.  That  they  are  not  the  outcome 
of  so-called  fcetcd  inclusions  is  proved  by  the  fact  of 
their  having  occasionally  been  found  to  contain  more 
than  a  hundred  teeth.  Tissues  of  epidermal  origin 
predominate,  hair,  horny  epithelial  buds,  and  teeth  ; 


470  Surgical  Pathology.       [Chap,  xciii. 

but  striated  muscle,  medullated  nerve-fibres,  nerve  cells, 
and  bone  have  all  been  seen.  The  hairs  are  usually 
shed  in  succession,  so  that  large  tufts  are  found  loose 
in  the  cavity  of  the  cyst,  embedded  in  desquamated 
epithelium  and  fatty  debris, 

I  put  up  a  specimen,  in  the  locu.li  of  which  were 
masses  of  fat  like  butter ;  the  cyst  walls  were  set  with 
piliferous  papillae. 

The  ovary  is  the  seat  of  election,  because  it  is 
destined  in  the  course  of  nature  to  produce  cells  that 
have  the  potentiality  of  developing  into  all  the  tissues 
of  the  body.  These  cysts  are  congenital,  or  occur  early 
in  life,  for  then  the  developmental  activity  is  great. 

Their  growth  may  extend  over  many  years.  On 
the  other  hand,  they  may  make  rapid  strides  after  a 
lengthened  period  of  quiescence.  A  patient  under  my 
observation  died  from  what  was  thought  to  be 
encephaloid  cancer  filling  the  abdomen,  but  post 
mortem  the  growth  turned  out  to  be  a  dermoid  cyst, 
which  contained  nothing  but  hair  and  pultaceous  epi- 
thelial debris. 

(4)  Cystic  sarcoma,  enchondroma,  etc.,  are  de- 
scribed under  their  respective  headings. 

Proliferating  ovarian  cysts. — The  origin  of  these 
cysts  is  doubtful.  It  is  more  likely  that  the  primary 
spaces  result  from  mucoid  or  colloid  softening  of 
aggregations  of  new  formation  cells,  than  that  they 
arise  from  distention  of  Graafian  follicles.  At  first 
they  are  small,  but  they  rapidly  enlarge  by  absorption 
of  the  intervening  walls,  and  by  the  addition  of  the 
softened  products  of  cell  proliferation.  They  become 
occupied  by  papillated  growths  that  spring  from  the 
inner  surface.  Secondary  cysts  are  formed  by  adhesion 
of  the  tips  of  contiguous  papillae  (W.  Fox),  or  by 
softening.  The  contents  of  compound  ovarian  cysts 
may  be  thin  and  serous^  but  more  often  the  fluid  is 
quite   viscid,   consisting  largely  of   mucin.      Cells   of 


Chap.  XCIIL]  CVSTS.  47  T 

various  sizes  and  in  different  stages  of  fatty  and  mucoid 
degeneration  are  suspended  in  it.  Occasionally  it 
sparkles  with  crystals  of  cholesterine.  It  may  be 
tinged  or  more  deeply  coloured  from  altered  blood. 
I  have  seen  heematoidin  crystals. 

The  cells  next  the  cavity  of  the  cysts  are  large  and 
distended  with  mucin,  or  granular  and  fatty.  Next 
come  polygonal  or  rounded  cells,  whilst  those  imme- 
diately lining  the  wall  are  generally  columnar.  Only 
the  last  are  seen  when  the  mucoid  transformation  is 
complete,  and  then  microscopical  sections  closely 
resemble  adenoma  or  even  columnar  epithelioma. 

Extravasation  cysts  are  very  common  in  soft 
malignant  growths,  such  as  encephaloid  cancer  and 
sarcoma.  Of  the  natural  tissues  the  brain  is  the  most 
likely  to  be  the  seat  of  cysts  as  the  consequence  of 
haemorrhage.  This  is  explained  by  the  physical  dis- 
abilities which  hinder  the  collapse  of  the  brain  tissue 
around  blood  clots  in  process  of  absorption,  viz.,  the 
peculiarity  of  the  intracranial  circulation  and  the 
fixity  of  the  cranial  walls. 

Hydatid  cysts.  —  Two  forms  of  hydatid  cyst 
occur  in  man,  echinococcus  and  cysticercus.  The 
former  is  the  cystic  stage  of  the  tape- worm  of  the  dog  ; 
the  latter  usually  of  the  ttenia  solium  of  the  human 
subject. 

Cysticercus  celliilosse  is  very  rare  in  man,  and 
never  attains  a  great  size.  It  has  been  observed  in 
the  humours  of  the  eye,  in  the  brain,  and  other  parts. 
The  animal  is  always  solitary  in  its  cyst. 

Ecliiiiococciis. — On  arriving  in  the  intestines 
the  ova  lose  their  envelopes,  and  the  embryos,  set  free, 
make  their  way  into  the  different  tissues  of  the  body. 
Their  transit  is  mainly  by  the  blood-vessels ;  hence 
the  frequency  of  hydatid  cysts  in  the  liver.  At  last 
they  settle  down,  and  become  encysted.  An  adven- 
titious fibrous  capsule  forms  around  the  essential  cyst. 


472 


Surgical  Pathology. 


[Chap.  XCIII. 


Secondary  and  tertiary  cysts  develop  within  the 
primary.  The  vesicles  vary  from  the  size  of  a  pea  to 
that  of  an  orange.  Each  is  composed  of  a  number  of 
superposed  parallel  laminee  of  perfectly  homogeneous 
.material,    an    appearance    quite     characteristic    (Fig. 


.-^  c 


Fig.  77. 

A,  Ova  of  tsenia  solium ;  b,  portion  of  fertile  cyst  showing,  a,  laminated 
membrane,  6,  ecliinococci  attached  to  germinal  layer,  e,  detached  booklets; 
c,  echinococcus ;  the  head  and  neck  are  withdrawn  within  the  caudal  vesicle. 
X  265. 


77,  B,  ci).  The  innermost  lamina  is  called  the  germinal 
membrane,  and  from  it  the  ecliinococci  develop.  The 
latter  look  like  white  specks  to  the  unaided  eye.  Each 
consists  of  a  head  and  neck,  which  are  usually  retracted 
within  the  caudal  vesicle  (Fig.  77,  c).  The  head  is  sur- 
mounted by  a  proboscis ;  it  carries  four  suckers  or 
vents,  and  two  circlets  of  spines. 

Unless    degenerated     the    cysts    are    transparent. 
They  give  a  peculiar  trembling  sensation  to  the  hand 


Chap. xciii.]  Hydatid  Cysts.  473 

(hydatid  thrill).  They  are  filled  with  clear  fluid,  which 
contains  a  little  common  salt,  but  no  albumin.  In 
the  fluid  detached  echinococci,  isolated  booklets,  and 
shreds  of  disintegrated  laminse  may  be  seen  at  times. 
I  lately  removed  a  hydatid  tumour  from  the  thigh  of 
a  woman  ;  it  had  been  growing  for  seven  years,  and 
was  larger  than  a  foetal  head.  Most,  if  not  all,  of  the 
cysts  were  barren  (acephalocysts). 

There  are  four  characteristic  diac?nostic  sisrns  of 
hydatid  cysts:  (1)  The  laminated  membrane;  (2) 
the  fluid  ;  (3)  echinococci ;  (4)  booklets.  To  seek  the 
last  two,  the  fluid  should  be  allowed  to  stand,  and  the 
lower  part  drawn  ofi^  with  a  pipette,  and  submitted  to 
the  microscope.  As  hydatid  cysts  enlarge,  the  con- 
tinuous pressure  causes  atrophy  of  the  surrounding 
tissues. 

Withdrawal  of  the  fluid  generally  sufiices  to  kill 
the  parasite,  and  put  a  stop  to  further  growth  of  the 
cyst. 

They  are  found  in  all  parts  of  the  body,  even  in 
the  bones. 

Secondary   changfes.  —  (1)    The   adventitious  _ 
cyst   may   calcify,   and  be  converted  into  a  kind   of 
carapace. 

(2)  Death  of  the  parasite,  and  shrinking  and  fold- 
ing up  (Fig.  2),  or  disintegration  of  the  cyst  walls. 
The  booklets  are  set  free  on  breaking  up  of  the  echi- 
nococci ;  they  may  be  found  in  the  oldest  cysts. 

(3)  Fatty  degeneration  and  caseation  of  the  walls 
of  the  cysts. 

(4)  Importation  of  foreign  matter ;  bile,  blood- 
pigment,  etc. 

Modes  of  teranination. — (1)  Obsolescence;  (2) 
suppuration  around  the  cyst ;  (3)  rupture,  with  its 
consequences  :  (a)  diffuse  inflammation  (peritonitis 
pleurisy) ;  (6)  hsemorrhage. 


474 


CHAPTER   XCTY. 

THE    CAECINOMATA. 

Type  :  epithelium.  There  are  two  forms,  alveolar 
and  "  epithelial,"  but  their  clinical  affinities  are  strongly- 
marked;  thus,  both  generalise  in  the  lymphatic  glands, 
and  almost  always  end  fatally. 

As  to  the  cause  of  cancer,  two  agencies  are  at 
work,  local  and  constitutional.  It  would  appear  that 
each  may  be  sufficient  in  itself,  but  there  can  be  no 
doubt  but  that  in  the  majority  of  cases  they  act 
together,  though  frequently  in  inverse  ratio. 

In  support  of  the  local  origin^  (1)  we  may  mention 
the  cases  where  continued  or  repeated  irritation  is 
followed  by  a  cancerous  growth,  e.g.^  epithelioma  of 
the  lip  and  tongue  from  the  friction  against  a  pipe  or 
tooth,  aijd  "chimney-sweep's  cancer  "  of  the  scrotum  ; 
(2)  taking  the  alimentary  canal,  it  is  at  the  places 
most  subject  to  friction  that  these  tumours  are  found  : 
lip,  tongue,  fauces,  upper  and  lower  ends  of  CESophagus, 
and  where  the  left  bronchus  crosses  it,  pylorus,  ileo- 
csecal  orifice,  rectum,  and  anus  ;  (3)  organs  that  are 
liable  to  vicissitudes  of  function,  as  the  mamma  in  the 
female. 

In  favour  of  the  constitutional  origin  are  (1) 
those  instances  where  no  unusual  irritation  can 
be  discovered ;  (2)  those  where  the  primary  outbreak 
is  multiple ;  and  (3)  those  where  hereditary  predis- 
position is  strongly  marked. 

No  age  is  exempt,  but  it  is  much  more  common 
at  and  beyond  mid-life.  The  disease  is  characterised 
by  a  continuous  non-inflammatory  local  growth _, usually 
repeated  in  distant  parts,  and  by  an  apyrexial  wasting 


Oiap.  xciv.]  The  Carcinomata,  475 

of  the  whole  body,  with  a  sallow,  greenish  yellow,  or 
leaden  hue  of  the  skin  (cachexia). 

Creneralisatiou  takes  place,  (1)  In  the  glands 
through  the  lymphatics,  and  this  explains  recurrence 
after  removal,  in  the  tissue  intervening  between  the 
primary  and  secondary  growth.  (2)  By  the  blood- 
vessels in  the  internal  organs  and  other  parts.  (3)  It 
may  be  that  where  a  nodule  projects  from  the  surface 
of  a  serous  membrane  particles  broken  off  may  settle 
down  and  form  new  centres  of  growth. 

The  tumour  grows  ( 1 )  by  multiplication  of  its  own 
elements  ;  (2)  by  a  "  spermatic  influence  "  upon  in- 
different cells  in  contact  with  it ;  (3)  by  discontinuous 
tubercles,  which,  at  first  isolated,  join  one  another 
and  the  main  growth  as  they  enlarge.  They  are 
probably  connected  by  the  lymphatics  from  the  first. 

Alveolar  cancer,  of  which  scii^rhus  is  the  type, 
shows  a  well-defined  structure,  in  which  the  cells  of 
epithelial  origin  are  packed  in  regular  spaces  or 
alveoli,  bounded  by  trabeculae  of  fibrous  tissue,  con- 
taining small  embryonic  corpuscles.  Blood-vessels 
and  lymjihatics  are  found  in  the  stroma,  but  only  the 
latter  enter  the  alveoli.  There  are  probably  no  in- 
trinsic nerves,  those  seen  in  sections  belongincr 
to  the  tissue  invaded  by  the  growth.  The  cells 
filling  the  alveoli  are  ^arge,  polymorphous  (round, 
angular  by  pressure,  tailed,  etc.),  and  contain  bright 
nucleolated  nuclei  Anatomically,  there  is  no  such 
thing  as  a  recognisable  "  cancer  cell ;  "  physiologically, 
no  doubt,  each  one  embodies  in  itself  all  the  attributes 
of  the  disease.  The  stroma  varies  greatly  in  amount, 
according  to  the  rate  of  growth  of  the  tumour ;  it  is 
usually  fibrous,  but  when  recent  it  often  appears  like 
spun  glass,  or  it  is  homogeneous. 

Scii'rlioiis  cancer  of  the  breast  is  very  hard, 
and  cannot  be  enucleated  from  the  tissue  in  which  it 
grows.     It  is   often  more   or   less  lobulated  on  the 


476  Surgical  Pathology.         [Chap.  xciv. 

surface.  On  section,  a  well-marked  cupping  is  ob- 
served, for  the  older  central  part  is  denser  and  more 
contractile  tlian  tlie  peri|)lieraL  To  the  naked  eye  it 
ap]oears  like  an  unripe  pear,  having  a  greyish  semi- 
translucent  look,  varied  by  yellow  streaks  and  specks, 
which  mark  alveoli  and  obstructed  milk  ducts  filled 
with  the  fatty  debris  of  degenerated  cells.  The 
gTOwing  marginal  zone  is  faintl}'^  pink,  for  here  as  yet 
the  vessels  are  intact. 

Not  seldom  small  cavities  are  to  be  seen,  the  re- 
sult of  obstruction  of  lymphatics  and  ducts ;  these 
contain  a  clear  pale  fluid,  or  this  variously  stained 
by  the  colouring  matter  of  the  blood.  I  have 
shown  that  as  a  rule  when  old  they  are  lined  by 
tesselated  epithelium.  During  life  a  clear  or  sanious 
fluid  sometimes  oozes  from  the  nipple  or  can  be  ex- 
pressed from  it.  The  fibrous  stroma,  as  it  slu'inks, 
obliterates  most  of  the  vessels ;  this  causes  degenei-a- 
tion  and  wasting  of  the  cells,  so  that  the  alveoli 
become  mere  chinks  filled  with  shrunken  cells  and 
gTanular  debris,  and  finally  disappear,  a  coarsely-grained 
cicatricial  tissue  being  all  that  remains.  Meanwhile 
the  tumour  increases  at  the  periphery,  and  destroys 
the  tissue  it  invades  and  infiltrates.  Other  thmgs 
being  equal,  the  rate  of  growth  varies  inversely,  and 
the  contraction  directly,  as  the  age  of  the  patient. 
In  old  women,  after  the  lapse  of  several  years,  what 
remains  (if  any)  of  the  diseased  gland,  together  with 
the  tumour,  may  be  of  less  bulk  than  the  healthy 
breast.     This  is  termed  rt2'?'c>;;>/^?c  scirrhus  (Fig.  78,  b). 

In  its  march  scirrhous  cancer  attacks  all  the 
structures  in  its  course,  so  that  it  becomes  adherent 
to  the  skin  over  it,  and  to  the  pectoral  muscle,  and,  it 
may  be,  the  ribs  and  pleura  beneath.  The  cicatricial 
contraction  accounts  for  the  wrinkling  and  puckering 
of  the  skin,  and  for  the  retraction  of  the  nipple. 
If  left  to  itself  the   skin    usually    becomes  inflamed 


Chap.  XCIV.]      SCIRRHUS    OF    THE   BrEAST. 


477 


and  then  ulcerated,  and  tlie  cancerous  tissue  covered 
by  a  layer  of  granulations  is  deeply  excavated;  or 
it  forms  a  jorotuberant  fungus.  In  some  cases 
nodules  are  seen  in  the  skin  around  the  central  growth ; 
in  fact,  the  skin  may  bear  the  brunt  of  the  mischief, 
being  thickly  studded  with  tubercles  that,  coalescing, 
constitute  the  cancer  en  cicirasse,  hide-bound  cancer, 
shield  cancer,  squirrhe  pustuleux  (Yelpeau). 

The  more  rapid  the  growth  the  more  likely  are 
the  axillary,  mediastinal  and  supraclavicular  glands  to 


Fig.  78. — Scirrhous  Cancer  of  the  Breast. 

A,  Rapidly  growing  form ;  b,  atropliied  or  cicatricial  scirrhiis.  Both  show 
alveolar  structure.  In  a  the  stroma  is  scanty  and  the  epithelial  cells  dis- 
tinct. In  B  the  stroma  is  dense  and  extensive,  the  alveoli  shrunken,  and  the 
contents  in  a  state  of  degeneration,    x  263. 


be  affected*  In  atrophic  scirrhiis  they  escape  for  a 
long  time,  but  eventually  they  are  involved,  with 
wide-spread  dissemination  in  the  internal  organs.  The 
male  breast  is  the  seat  of  the  disease  in  about  two  per 
cent,  of  the  cases  (Paget). 

Cancer  of  the  breast  is  sometimes  "  acinous ;" 
tliat  is,  the  original  outline  of  the  gland  acini  is  more 
or  less  preserved;  this  accords  with  the  lobulated 
outline  of  these  growths.  But  there  is  a  "  tubular  " 
variety,  in  which  the  cancer  cells  permeate  the  gland 
tissue  in  narrow  columns ;    the   ditierence,   I  believe, 


47^  Surgical  Pathology.        [Chap.  xciv. 

depends  upon  tlie  point  of  departure  of  the  new- 
epithelial  formation ;  in  the  latter  instance  (tubular) 
it  probably  starts  in  a  hyperplasia  of  the  cells  lining 
the  ducts. 

An  eczematous  condition  of  the  nipple  may 
precede  the  development  of  duct  cancer  in  the  gland 
by  months  or  years.  The  obstinacy  of  the  eruption 
and  its  circumscribed  margin  show  that  it  is  not 
a  simple  eczema,  and  against  its  being  primarily 
cancerous  is  its  long  duration ;  but  it  may  be  that 
ordinary  glandular  cancer  in  some  cases  commences  in 
a  slow  derangement  of  nutrition  of  the  epithelium, 
not  thought  of  because  not  seen,  and  that  it  is  only 
later  that  it  manifests  itself  in  an  open  "  rebellion  of 
cells."  Analogous  to  the  above  is  epithelioma,  as  a 
sequel  to  "  psoriasis  "  of  the  tongue. 

Microscopy. — To  understand  the  minute  anatomy 
of  scirrhus,  sections  should  be  made  of  different 
tumours  and  different  parts  of  each.  In  a  rapidly 
growing  scirrhus  the  stroma  at  the  periphery  is 
imperfectly  fibrillated,  sometimes  quite  homogeneous, 
but  in  the  older  portions  the  fibrous  trabeculse  are 
very  distinct.  There  is  a  marked  relative  increase  as 
we  near  the  centre  of  the  growth,  for  as  the  cicatricial 
contraction  obliterates  the  vessels,  the  cells  atrophy 
and  the  stroma  shrinks,  so  that  the  alveoli  get  smaller 
and  smaller.  The  more  rapid  and  recent  the  growth 
tlie  more  is  the  stroma  infiltrated  with  embryonic 
cells,  which  are  sometimes  so  numerous  as  to  hide 
the  matrix.  The  alveoli  vary  in  size  and  shape  from 
the  first,  but  are  for  the  most  part  fusiform,  and 
double  the  width  of  the  trabeculse  bounding:  them. 
They  are  not  closed  spaces,  as  they  at  first  sight  appear, 
for  they  constitute  a  system  of  intersecting  canals, 
which  can  be  seen  in  thick  sections  by  altering  the 
focus  of  the  microscope.  As  the  stroma  shrinks  they 
necessarily  diminish  in  size.    The  cells  filling  the  alveoli 


Chap,  xciv.]        Encephaloid  Cancer.  479 

are  variously  shaped,  round,  angular,  tailed,  etc.,  ac- 
cording to  the  extent  of  the  pressure  upon  them. 
Their  size  is  in  marked  contrast  with  the  indifferent 
corpuscles  of  the  stroma. 

Except  at  the  periphery,  the  blood-vessels  can  only 
be  seen  in  injected  specimens.  They  become  throm- 
bosed through  the  contraction  of  the  stroma.  In  the 
oldest  portions  of  the  growth  they  disappear,  from 
atrophy  of  their  walls.  It  is  said  that  by  the  aid  of 
nitrate  of  silver  the  lym^phatics  can  be  traced  in  fresh 
specimens  into  the  alveoli. 

Any  fat  cells  met  with  in  the  tumour  belong  to 
the  tissue  invaded.  The  epithelial  cells  of  cancer 
never  become  distended  with  fat  drops.  In  this  way 
they  differ  from  some  cases  of  sarcoma. 

Siiceplialoid  cancers  have  exactly  the  same 
structural  arrangement  as  scirrhous,  but  differ  from  the 
latter  in  the  relative  amount  of  stroma  and  cells. 
They  are  usually  soft,  brain-like  tumours,  though 
sometimes  they  are  moderately  firm  in  consistence. 
The  alveoli  are  larger  than  in  scirrhous,  and  the 
trabeculse  for  the  most  part  more  delicate.  Moreover, 
-their  tendency  is  to  degenerate  and  soften;  in  fact, 
they  may  be  diffluent  in  the  older  portions,  or  even 
throughout ;  hence  haemorrhages  into  their  substance 
are  common.  When  the  surface  becomes  ulcerated 
the  unrestrained  growth  protrudes  in  the  form  of 
'■'■fungus  hcernatodesJ^  They  are  so  elastic  that  they 
often  give  a  sense  of  fluctuation.  In  colour  they  are 
yellowish-white,  mottled,  or  flecked  with  red;  here  and 
there  may  be  seen  patches  of  modena  hue,  from 
capillary  extravasations.  Blood-cysts  are  not  un- 
common. Usually  of  rapid  growth,  and  very  malignant, 
there  is^  nevertheless,  a  wide  range  in  morbid  appear- 
ances and  clinical  course. 

In  St.  Mary's  museum  is  a  specimen  of  encephaloid 
can.cer  of  the  testicle,  removed  during  life;  it  is  firm 


48o 


Surgical  Pathology. 


[Chap  xciv. 


and  fibrous  in  one  half  its  bulk,  pultaceous  in  tLe 
other.  The  tumour,  as  large  as  a  foetal  head,  had 
been  growing  for  four  years  without  any  signs  of 
thickening  of  the  cord,  secondary  growth,  or  con- 
stitutional taint. 

Both  scirrhous  and  encephaloid  yield  a  milky  juice 
on  scraping. 

Microscopy. — The  alveoli  are  large,  and  round 
or  oval  in  shape,  rarely  narrow  and  fusiform  as  in 
scirrhus.      The  stroma  is  subject  to  great  variation 

both  in  nature  and 
extent.  It  gene- 
rally forms  delicate 
overarching  bands 
(Fig.  79,  h),  but  at 
times  wide  dense 
trabeculse  can  be 
seen ;  but  even  then 
we  do  not  find  the 
shrunken  alveoli 
so  constant  in 
scirrhus.  It  may 
be  entirely  fibril- 
lated,  or  consist  of 
a  few  fine  fibres 
traversing  a  homo- 
geneous matrix.  It  may  be  almost  devoid  of  in- 
different cells,  or  thickly  strewn  with  them.  The 
epithelial  cells  filling  the  alveoli  are  large.  They  are 
not  so  multiform  as  in  scirrhus,  for  the  intercellular 
substance  is  less  dense  and  more  copious  ;  and  hence 
the  cells  are  not  so  liable  to  alterations  in  shape  from 
pressure.  They  contain  large  nuclei,  one  or  more  in 
each  cell,  with  bright  highly  refractive  nucleoli. 
When  the  cells  are  undergoing  degeneration  fat 
particles  make  their  appearance  in  the  protoplasm. 
The  vessels  are  wide,  and  have  very  thin  walls,  and 


I^ig.  79.— Encephaloid  Cancer  of  the  Testicle 
a.  Epithelial  cells  ;  b,  flljrous  stroma,    x  265. 


Chap,  xciv.]  Adenoid  Cancer.  48 1 

from  defective  and  unequal  support  they  develop  am- 
pullary  dilatations.  These  frequently  rupture,  and 
give  rise  to  extravasation  of  blood. 

Adenoid  cancer;  colunuiar  epitlielioma. 

— This  variety  affects  the  stomach  and  intestines 
(especially  the  rectum),  the  bladder,  ovary,  cervix 
uteri,  nasal  fossae,  and  the  jaws.  In  the  last-mentioned 
situation  it  starts  from  the  gums,  or,  in  the  case 
of  the  upper  jaw,  the  lining  membrane  of  the  antrum. 
The  pattern  is  exquisitely  alveolar,  like  a  piece  of 
mosaic.  The  stroma  is  now  scanty  and  delicate,  and 
a^ain  excessive  and  coarsely  fibrillated,  the  variation 
being  often  marked  in  the  same  specimen.  In 
some  parts  it  is  almost  free  from  corpuscles,  in  others 
crowded  with  small  round,  indifferent  cells.  The 
epithelial  cells  line  the  acini  with  great  regularity. 
They  are  large,  columnar,  and  have  bright  elongated 
nuclei  (Fig.  59).  Sometimes  they  become  distended 
with  mucin,  and  present  an  inflated  appearance. 
The  tumour,  when  it  reaches  the  surface,  quickly 
ulcerates,  and,  being  very  vascular,  bleeds  profusely, 
the  more  so  when  subjected  to  mechanical  irritation; 
e.g.,  by  the  passage  of  faeces  over  it. 

It  has  a  less  tendency  than  scirrhous  or  en- 
cephaloid  to  generalise  in  the  lymphatic  glands. 
In  the  case  of  the  rectum  secondary  growths  are 
disseminated  in  the  liver.  The  path  of  infection 
would  seem  to  be  along  the  branches  of  the  portal 
system.  These  secondary  growths  in  the  liver  possess 
the  same  glandular  disposition  and  shape  of  the 
epithelial  cells  as  the  primary  lesion. 

I  have  observed  a  columnar  epithelioma  of 
the  bladder  in  which  the  alveoli  were  separated  by  a 
very  scanty  stroma,  and  the  cells,  arranged  in  super- 
posed columns,  completely  filling  the  spaces. 

In  the  jaws,  particularly  the  lower,  the  central 
cells  are  round,   or  angular  by  compression,   and  the 

F  F 


482  Surgical  Pathology.         [Chap.  xciv. 

peripheral  columnar.  In  this  situation  the  new 
formation  is  almost  invariably  cystic,  and  it  is  note- 
worthy that  only  the  central  cells  undergo  mucoid 
degeneration,  the  columnar  ones  at  the  periphery 
remaining  as  an  epithelial  lining  to  the  cysts  (Fig.  5). 
Here,  too,  the  interacinose  tissue  is  fibrous,  or  composed 
of  spindle-shaped  cells;  in  the  latter  case  the  growth  has 
for  this  reason  been  mistaken  for  sarcoma.  Cystic 
epithelioma  of  the  jaw  is  slow  in  its  progress,  and  has 
but  little  tendency  to  involve  either  the  lymphatic 
glands,  or  the  internal  organs. 

Colloid  cancer  is  built  upon  the  same  structural 
type  as  scirrhous  and  encephaloid.  It  bears  a  close 
resemblance  to  the  latter  in  its  clinical  features,  being 
rapid  in  growth,  and  quickly  fatal.  It  selects  for  its 
ravages  many  different  tissues,  but  the  bulk  of  the 
cases  is  met  with  in  the  abdominal  viscera,  especially 
the  intestinal  tract  and  the  ovaries.  The  peritoneum 
is  often  seen  to  be  infiltrated ;  but  on  the  assumption 
that  all  cancers  start  from  pre-existing  epithelium,  it 
must  be  granted  that  these  omental  and  mesenteric 
growths  begin  in  the  stomach,  intestine,  pancreas, 
or  liver,  since  the  epithelioid  lining  of  the  peritoneum 
belongs  to  the  connective  tissue  series.  The  open 
meshwork  of  the  serous  membrane  is  a  favourable 
ground  for  the  spread  of  the  disease,  richly  provided 
as  it  is  with  blood-vessels  and  lymphatics. 

The  consistence  of  these  tumours  is  subject  to 
wide  variation,  but  for  the  most  part  they  are  very 
soft,  sometimes  diffluent.  When  springing  from  the 
ovary  they  may  be  mistaken  for  simple  cystic  for- 
mations. 

Cancer  is  rare  in  the  thyroid  hody^  but  when  it 
occurs  colloid  matter  is  seldom  absent.  In  this  way 
it  conforms  to  the  rule  that  most  of  the  morbid  changes 
found  in  the  gland  are  accompanied  by  colloid  degener- 
ation.    The  alveoli  are  laro-er  and  less  angular  than  in 


Chap.  XCIV.] 


Colloid   Cancer. 


483 


scirrhus,  for  the  colloid  transformation  gives  rise  to 
an  increase  in  bulk,  and  this  expands  the  walls  of  the 
spaces,  and  renders  the  latter  globular  or  ovoid.  The 
degeneration  commences  in  the  cells.  First  a  drop 
appears  in  the  protoplasm,  and  as  it  enlarges  the 
nucleus  is  thrust  to  the  margin.  Finally,  nuclei  and 
cell  capsules  disappear.     The  change  advances  from 


Fig.  80.— Colloid  Cancer  of  tlie  Ovary. 

a,  Fibrous  stroma;  6,  eel!  distended  witb  di'op  of  colloid  material;  c,  alveolus. 
The  cells  that  occupied  the  centre  have  disappeared,  and  in  their  place  a 
semi-homogeneous  mass  marked  hy  concentric  streaks  can  he  seen.  The 
periphei'al  cells  are  flattened  from  the  pressure  of  the  colloid  suhstance, 
X  365. 

the  centre  to  the  periphery,  and  the  outside  cells, 
prior  to  their  destruction,  become  compressed  and 
elongated,  and  occupy  a  concentric  position  (Fig.  80). 
The  stroma  undergoes  a  similar  alteration,  it  softens 
and  liquefies,  so  that  contiguous  alveoli  run  together, 
forming  festooned  cavities. 

These  anfractuous  spaces,  bounded  by  tracts  of 
fibrous  tissue,  give  an  alveolar  disposition  that  can  be 
seen  by  the  naked  eye.  The  secondary  growths  are  of 
the  same  nature  as  the  primary. 


484  Surgical  Pathology.  .      [Chap.  xciv. 

Squamous  epithelioma,  also  called  epithelial 
cancer,  in  contradistinction  to  scirrhous  and  encepha- 
loid,  which  were  formerly  believed  to  be  connective 
tissue  tumours,  and  are  so  to  this  day  by  Cornil  and 
Ranvier.  The  prevailing  idea  of  their  nature  negatives 
this  differentiation,  since  most  pathologists  maintain 
that  all  cancers  start  from  pre-existing  epitheliunL 
There  can  be  no  question  but  that  this  is  the  case  with 
the  growths  under  consideration.  Whatever  their  strucr 
tural  relationship  may  be  to  other  forms  of  cancer, 
they  possess  certain  well-defined  anatomical  and 
clinical  characters.  They  are  found  for  the  most  part 
in  situations  that  admit  of  their  operative  treatment, 
and  they  illustrate  the  principle  that  local  irritation  is 
a  noteworthy  factor  in  the  etiology  of  malignant 
growths,  whether  this  be  in  the  form  of  a  precedent 
inflammatory  lesion,  e.g.,  syphilitic  ulcer  of  the 
tongue,  or  mechanical  friction,  as  from  a  sharp  tooth 
or  the  stem  of  a  pipe.  Their  tendency  to  develop  at  the 
junction  of  skin  with  mucous  membrane  is  well  known, 
but  this  is  explained  rather  by  the  coincidence  that 
these  are  the  very  places  most  exposed  to  irritation, 
than  by  any  inherent  disposition  of  the  epithelium  to 
perverted  growth.  That  the  surface  epithelium  pre- 
ponderates in  the  lips,  e.g.,  as  age  advances,  is  no 
proof  that  its  nutritive  activity  is  greater.  The 
increase  is  relative  rather  than  absolute,  for  in  old 
peojDle  the  connective  tissue  and  muscular  fibres 
waste.  The  favourite  situations  where  skin  and 
mucous  membranes  meet,  are  the  lijjs,  genital  organs, 
and  anus.  The  general  cutaneous  surface  is  by  no 
means  exempt;  the  face  and  back  of  the  hand  take 
the  lead,  unless,  perhaps,  we  exclude  the  skin  of 
the  leg,  where-  some  simple  chronic  ulcers  at  length 
become  cancerous. 

The  mucous   membranes,  naturally   covered  with 
laminated  scaly  epithelium   (e.g.,  the  tongue,   cheek, 


Chap,  xciv.]      Squamous  Epithelioma.  '      485 

fauces,  oesopliagiis,  vagina,  and  cervix  uteri),  are  all 
liable  to  the  inroads  of  tlie  disease.  In  the  bladder 
the  deep  epithelial  cells  are  columnar,  and  the  super- 
ficial flattened  ;  hence  in  this  viscus  both  squamous 
and  columnar  epithelioma  are  met  with.  Epithelioma 
of  the  scrotum  is  kno"svn  as  chimney-sweep's  cancer, 
it  being  thought  that  the  friction  of  the  sharp  par- 
ticles of  soot  keeps  up  a  chronic  irritation ;  and  some 
weight  is  given  to  this  view  by  the  fact  that  the  dis- 
ease is  less  common  than  formerly,  when  chimneys 
were  swept  by  climbing. 

The  first  efiect  of  the  local  irritation  is  to  cause  a 
simple  inflammatory  hyperplasia,  and  this  may  go  on 
for  a  long  time  before  any  specific  epithelial  over- 
growth takes  place.  Eventually  this  does  happen,  and 
the  multiplication  of  cells  proceeds  from  the  deeper 
layers  of  the  epidermis  and  its  involutions — the  hair- 
follicles,  sebaceous  and  sweat  glands.  In  some  cases 
this  is  mainly  confined  to  the  surface — in  others  it 
infiltrates  the  structures  beneath.  There  is  great 
variety  in  this  respect. 

Rod-like  masses  of  epithelium  advance  in  the 
direction  of  least  resistance,  i.e.,  between  the  bundles 
of  connective  tissue,  it  is  said,  in  the  lymphatic  spaces. 
If  this  be  so,  we  have  a  ready  explanation  of  specific 
infection  of  the  lymphatic  glands  next  in  order  to  the 
primary  growth.  These  epithelial  cylinders  send  off 
buds  in  various  directions,  which  increase  at  the 
periphery,  and  thus  form  the  well-known  "  epidermal 
globes  '^  or  "epithelial  pearls."  Concentric  lamination 
of  the  cells  explains  the  characteristic  "  bird's  nest " 
appearance  on  section  (Fig.  81).  This  lamination  is  the 
result  of  pressure,  aided  by  the  shrinking  of  the  older 
epithelial  cells  as  they  become  horny ;  the  latter  process 
is  a  repetition  of  what  takes  place  physiologically  in 
the  superficial  layers  of  the  epidermis.  The  "  globes  " 
are  not  all  isolated  groups  of  cells,  but  many  are  the 


486 


Surgical  Pathology. 


[Shap.  xciv. 


transverse  sections  of  the  down-growing  columns  above 
referred  to.  Some  are  microscopical,  but  others  can 
be  seen  by  the  naked  eye  as  yellowish  spots,  embedded 
in  the  indifferent  s^rowth  that  surrounds  them.     As  the 


Fig.  81. — From  an  Epithelioma  of  the  Thumb. 

a.  Epithelial  "nest "  ;  6,  large  polj-gonal  cells  mai-ked  hy  fine  striations  at  their 
borders ;  c,  indifEerent  tissue ;  d,  sweat  duct.    X  265. 


epithelial  cylinders  increase  in  size  they  project  from, 
the  surface,  giving  it  a  granular  appearance.  By 
pressure  they  can  be  squeezed  out  like  the  contents  of 
a  sebaceous  gland.  The  peculiar  hardness  of  this  form 
of  epithelioma  (useful  in  diagnosis)  is  due  to  the  corni- 
fication  of  the  older  cells  in  the   same  way  that   the 


chnp.  xciv.]      Squamous  Epithelioma.  487 

epidermis,  -vritli  its  appendages,  the   hairs  and  nails, 
becomes  horny, 

Now  picro  -  carmine  with  an  excess  of  picric 
acid  stains  the  rete  mucosum  red,  and  the  cuticle 
bright  yellow;  and  as  the  same  chemical  changes  occur 
in  the  cell-columns  of  epithelioma  as  is  found  in 
the  normal  evolution  of  epidermis,  and  as  these 
columns  increase  in  width  mainly  by  the  addition  of 
new  cells  to  the  periphery,  it  follows  that  the  central 
cells  of  the  epithelial  nests  should  be  stained  yellow, 
and  the  outer  ones  red,  and  so  it  is  found  in  the 
greater  numbjr  of  cases.  In  some,  however,  the 
central  cells  continue  to  enlarge  and  multiply,  whilst 
the  peripheral  ones  become  compressed ;  the  result  is 
a  collection  of  large  spherical,  polygonal,  or  oval  cells, 
surrounded  by  laminae  of  flattened  epithelium. 

The  connective  tissue  and  other  structures  invaded 
by  the  proliferating  epithelium  show  an  irritative 
liyperplasia.  Indifferent  cells  crowd  the  stroma.  The 
old  blood-vessels  dilate  and  new  ones  ai-e  formed.  The 
inflammatory  new  formation  leads  to  softening  and 
ulceration.  The  destruction  progresses  from  without 
in.  In  some  cases  the  gTowth  has  but  little  tendency 
to  spread  deeply,  but  gives  rise  to  large  branched 
projections,  termed  caulijiovjer  excrescences.  The 
blood-vessels  being  less  compressed  than  in  the  infil- 
trating variety,  the  necrosis  of  tissue  is  not  so  gTeat ; 
in  fact,  at  first  sight  it  is  diflicult  to  say  whether  the 
tumour  be  a  papilloma  or  a  papillary  epithelioma. 
Closer  examination  reveals  some  invasion  of  the  tissues 
beneath  the  base  of  attachment,  and  perh-aps  also 
lymphatic  enlargement.  A  parallel  case  is  furnished 
by  the  simple  villous  tumour  and  villous  cancer  of  the 
bladder.  However  great  the  ulceration  and  sloughing 
may  be,  the  constructive  process  is  always  greater 
than  the  destructive ;  the  epithelial  and  inflammatory 
formation  is  heaped  around  the  ragged  margins  of  a 


488  Surgical  Pathology.        rchap. xciv. 

deeply  excavated  ulcer,  and  projects  in  nodules  from 
the  indurated  base. 

There  is  great  variation  in  the  degree  of  malig- 
nancy. Some  cases  recur  rapidly  after  removal,  infect 
the  lymphatic  glands  early,  break  down  into  gangrenous 
sores  with  foul  discharge,  and  end  fatally  within 
twelve  montlis.  Others  take  years  to  run  their 
course,  and  some  are  completely  eradicated  by  ope- 
ration. The  more  vascular  the  tissue  affected  the 
graver  is  the  prognosis.  In  epithelioma  of  the  tongue 
and  mouth  the  general  emaciation  and  discomfort  are 
increased  by  the  pain  and  difficulty  in  swallowing,  and 
matters  are  not  mended  by  the  passage  of  decomposing 
discharges  into  the  stomach  and  lungs. 

Capillary  and  even  arterial  bleeding  from  ulcerated 
epithelioma  is  a  great  source  of  distress.  It  is  often 
difficult  to  stop,  and  it  recurs  after  short  intervals,  for 
the  blood-vessels  cannot  contract,  and  fresh  ones  are 
opened  by  ulceration  and  sloughing. 

The  secondary  deposits  in  the  lymphatic  glands 
have  the  same  histological  characters  as  the  primary 
growth.     Infection  of  the  internal  organs  is  rarely  seen. 

Microscopy. — If  a  vertical  section  be  made 
through  the  margin  and  base  of  an  ulcerated  cutaneous 
epithelioma,  it  will  be  observed  that  the  cells  pass  in 
columns  into  the  subjacent  structures.  These  columns 
follow  the  course  of  the  hair  follicles,  sweat  ducts,  and 
sebaceous  glands.  They  are  not,  however,  confined  to 
them,  but  ramify  in  the  interstices  of  connective  tissue. 
Since  the  buddings  from  the  columns  lie  in  different 
planes  many  are  divided  transversely  and  obliquely, 
giving  one  the  idea  of  isolated  cell  masses.  The 
characteristic  arrangement  in  concentric  laminae  has 
already  been  alluded  to  as  the  result  of  lateral  pressure, 
and  shrinking  of  the  older  cells  from  cornification. 
The  flattening  of  the  cells  is  in  parts  so  complete  that 
they  look  like  fibres.     Their  real  nature  is  manifest  in 


Chap,  xciv.]      Squamous  Epithelioma.  489 

the  gradations  of  size  and  shape,  from  the  centre  to 
the  periphery  of  the  "epithelial  globes."  Moreover, 
they  can  be  isolated  by  the  aid  of  liquor  potassse  and 
teazing.  The  epithelial  cells  adhere  firmly  to  one 
another  either  directly  or  through  the  medium  of  a 
scanty  intercellular  substance. 

Many  appear  to  interlock  by  fine  serrations  at 
their  margins  (stachel  and  riif  cells)   (Fig.  81,  6). 

The  epithelial  masses  are  surrounded  by  connective 
tissue  studded  with  indifferent  cells. 

In  some  cases  it  is  very  scanty,  in  others  it  exceeds 
in  amount  the  epithelial  portion  of  the  growth.  The 
ground  substance  appears  homogeneous,  or  more  or  less 
perfectly  fibrillated.  The  extent  of  the  small-celled 
infiltration  varies  much  in  different  cases  :  generally 
speaking  it  may  be  said  to  be  directly  proportionate  to 
the  rapidity  of  growth,  and  the  tendency  to  ulceration, 
and  so  to  the  local  malignancy  of  the  disease. 

The  epithelial  columns  enlarge  by  segmentation 
and  endogenous  formation  of  their  own  cells,  and  by 
the  conversion  and  appropriation  of  indifferent  cells  at 
the  margin. 

Blood-vessels  ramify  in  the  stroma,  but  do  not 
enter  the  epithelial  masses,  which  may  therefore  be 
said  to  be  extravascular. 

The  stroma  is  less  distinctly  alveolate  than  in  the 
other  forms  of  cancer. 

The  individual  cells  are  very  large,  averaging  y^ 
inch  in  diameter.  They  do  not  show  such  diversity  of 
outline  as  in  scirrhous  and  encephaloid.  Cornification 
of  the  cells  is  characteristic  of  this  form  of  cancer. 
The  intercellular  substance  is  much  more  scanty  than 
in  alveolar  cancer. 

Secondary  changes  in  ejnthelioma. — Inflammation 
and  ulceration  are  constant.  Tatty,  mucoid,  and 
pigmentary  degeneration  of  the  epithelial  cells  com- 
paratively rare. 


490  Surgical  Pathology.         [Chap.  xciv. 

Rodent  ulcer  may  be  conveniently  discussed 
here.  Until  lately  it  was  considered  to  be  distinct 
from  epithelioma  in  its  structure  and  clinical  course. 
Paget  says  "  it  does  not  contain  epidermal  globes,  nor 
any  other  elements  of  a  cancerous  nature ;  "  but  later 
observations  have  shown  that  this  view  is  not  correct, 
and  that  too  great  a  similarity  exists  between  rodent 
ulcer  and  the  more  chronic  forms  of  epithelioma  to 
justify  its  being  regarded  as  other  than  "the  least  ex- 
pressed form  of  malignant  disease"  (T.  Fox). 

Rarely  beginning  before  the  fiftieth  year,  it  pursues 
a  steady  and  certain  course,  so  slow  that  after  several 
years  it  may  not  exceed  the  size  of  a  florin.  The 
lymphatic  glands  may  become  enlarged  from  simple 
irritation,  and  even  suppurate  (Moore),  but  they  are 
not  liable  to  specific  deposit  by  infection  from  the 
primary  growth.  In  its  ravages  rodent  ulcer  spares 
no  tissue,  not  even  bone.  Disseminated  nodules 
around  the  primary  lesion  are  generally  absent.  The 
older  central  part  of  the  ulcer  may  dry  up,  but  there 
is  little  or  no  approach  to  cicatricial  contraction.  The 
face  is  the  favourite  locality,  though  the  disease  is 
met  with  in  other  situations.  The  cellular  elements 
composing  the  walls  and  base  are  for  the  most 
part  the  same  as  in  simple  chronic  ulcers,  but 
there  is  in  addition  a  decided  epitlielial  proliferation. 
It  is  true  the  cells  are  smaller  than  in  ordinary 
epithelioma,  but  like  them  they  show  a  disposition, 
remote  though  it  be,  to  concentric  lamination.  The 
new  formation  commences  as  a  hyperplasia  of  the 
epithelial  cells  of  the  sebaceous  and  sweat  glands.  The 
rete  Malpighii  becomes  atrophied  by  the  pressure  of 
the  growth  beneath,  but  it  manifests  little  tendency  to 
active  change ;  this  is  in  marked  contrast  to  the  part 
it  Inlays  in  the  common  variety  of  epithelioma. 

Extensive  local  destruction  of  tissue  is  compatible 
with  the  most  perfect  general  health. 


Chip,  xciv.]       Can'Cers  axd  Sarcomas.  491 

Early  and  complete  removal  offers  a  reasonable 
expectation  of  a  radical  cure. 

Cancers   contrasted  Tv^ith   sarcomas. — (1) 

According  to  Waldeyer^  Billroth,  and  most  English 
pathologists,  all  cancers  are  develojDed  from  pre- 
existing e2:)ithelium.  There  is  no  difference  of  opinion 
as  to  the  origin  of  epithelioma,  but  the  alveolar  form 
(scirrhous  and  encephaloid)  is  asserted  by  Cornil  and 
Rmvier  to  commence  in  a  proliferation  of  the  con- 
njctive  tissue  cells.  They  say  that  if  Prussian  blue 
be  injected  into  the  tumour,  it  will  pass  along  a 
continuous  path  formed  by  cancerous  alveoli  and 
lymphatic  vessels,  and  that  the  same  arrangement  will 
be  observed  in  fresh  sections  stained  with  nitrate  of 
silver,  the  endothelial  connective  tissue  lining  of  the 
lymphatics  passing  directly  into  the  groups  of  cells 
filling  the  alveoli.  In  this  way  they  account  for  the 
constancy  of  generalisation  in  the  glands  first  in  order 
from  the  primary  growth  ;  but  it  is  one  tiring  to  show 
an  anatomical  connection  between  the  cancerous 
elements  and  the  lymphatics,  and  another  to  prove 
that  one  springs  from  the  other.  Besides,  epithelioma, 
which  they  allow  begins  in  a  proliferation  of  epithe- 
lium, also  proj^agates  itself  in  the  next  absorbent 
glands. 

Dr.  Thm  has  shown  that  beneath  the  basement 
membrane  of  duct  cancer  there  is  a  delicate  feltwork 
of  interlacing  elastic  fibres,  similar  to  that  described 
by  Henle  around  the  milk  ducts  of  the  breast. 

Sarcoma  has  its  type  in  embryonic  connective 
tissue. 

(2)  Arrangement  of  constituent  elements. — In 
alveolar  cancer  this  is  very  definite,  the  cells  being 
contained  in  sj)aces  which  intersect  in  all  directions, 
like  a  labyrinth,  forming  a  cavernous  structure.  The 
stroma  bounding  these  spaces  consists  of  fibrous  tissue, 
in  which  the  blood-vessels  are  distributed. 


492  Surgical  Pathology.         [Chap.  xciv. 

In  sarcoma  the  cells  are  embedded  in  a  ground 
substance,  homogeneous  or  fibrous.  The  bundles  of 
fibres,  when  present,  follow  the  course  of  the  vessels, 
and  do  not  arch  over  and  construct  alveoli.  The 
vessels  may  be  considered  as  one  great  system  of 
capillaries,  whose  walls  are  formed  of  the  cells  of  the 
tumour  itself. 

(3)  Mode  of  generalisation.-— CsiiiCGYS  disseminate 
chiefly  by  the  lymphatics,  as  might  be  inferred  from 
the  close  anatomical  connection  between  them.  The 
infecting  material  of  sarcomas  is  conveyed,  in  the 
majority  of  cases,  directly  by  the  blood-vessels,  and 
the  secondary  growths  are  for  the  most  part  found  in 
the  internal  organs.  Even  when  the  glands  are 
affected,  it  may  be  through  the  blood-vessels,  for  the 
intermediate  lymphatics  are  not  always  infiltrated. 
Moreover,  the  glands  may  be  attacked  by  a  con- 
tinuous invasion  from  the  primary  growth,  and  not 
specially  through  the  lymph  channels.  And,  again, 
the  initial  cause  of  the  disease  in  some  cases  selects 
the  lymphatic  glands  for  its  ravages,  so  that  it  is  not 
a  question  of  dissemination  at  all. 

(4)  Encapsulation. — When  sarcomas  spring  from 
fasciae,  the  sheaths  of  muscles,  and  some  other  struc- 
tures, they  often  present  a  well-defined  capsule,  and 
can  he  shelled  out  of  their  bed,  except  at  their 
base  of  attachment,  and  the  slower  the  growth  the 
more  easily  can  this  be  done.  Cancers,  on  the  other 
hand,  infiltrate  the  surrounding  tissue,  showing  a 
complete  absence  of  a  true  capsule,  unless  it  be  by 
chance  derived  from  the  fibrous  tissue  of  an  organ 
destroyed  by  the  growth,  e.g.,  the  testicle.  In  many 
cases  sarcomas  aj^pear  as  indefinite  in  outline  as 
cancers.  This  is  well  seen  in  the  bones  and  in  the 
internal  organs,  so  too  much  stress  must  not  be  laid 
on  this  difference  between  the  two  groups  of  tumours. 

(5)  Taking  them  all  together,  it  may  be  affirmed 


Chap,  xciv.]       Cancers  and  Sarcomas.  493 

that  sarcomas  are  less  liable  to  recur  after  removal^ 
but  the  more  malignant  vie  with  cancers  in  this 
respect,  whilst  in  the  extent  and  the  early  period  of 
their  generalisation  they  sometimes  outstrip  them. 

(6)  Cachexia. — It  is  by  no  means  rare  to  find  a 
sarcoma  of  enormous  size,  the  patient  being  in  good 
general  health ;  whereas  the  constitutional  signs  of 
cancer  are  generally  well  marked,  and  often  at  an 
early  stage,  so  much  so  that  a  cachectic  appearance 
is  a  valuable  aid  to  diagnosis.  When,  however,  the 
generalisation  of  sarcoma  is  extensive,  and  still  more 
when  the  primary  growth  has  ulcerated,  the  wasting 
of  the  body  and  sallowness  of  the  skin  are  very 
manifest. 

(7)  Age  of  the  patient. -  -Sarcomas  are  prone  to 
occur  earlier  in  life  than  cancers,  which  seems  only 
natural,  considering  they  are  formed  upon  the  type  of 
embryonic  tissue,  which  is  indifferent  in  striicture, 
and  possessed  of  great  nutritive  and  formative  activity. 
This  difference  only  holds  good  within  certain  limits, 
for  the  majority  of  cases  of  malignant  disease  of  the 
testis,  both  cancerous  and  sarcomatous,  occur  between 
the  ages  of  thirty  and  forty-five  (Butlin)  ;  but  even 
here  there  is  a  greater  liability  to  sarcoma  than  to 
cancer  during  the  first  decade  of  life. 

(8)  Nutritive  changes. — Sarcomas,  consisting  as 
they  do  of  unstable  developmental  tissue,  are  liable  to 
greater  variation  from  secondary  changes  than  cancers, 
whether  it  be  towards  a  higher  phase  of  evolution,  as 
in  the  tendency  to  form  cartilage  or  bone,  or  to  a 
decline  in  vital  activity,  as  in  calcification  and  the 
formation  of  cysts  from  mucoid  softening;  or  to  a 
perversion  of  normal  nutrition,  as  when  they  become 
melanotic  in  the  tissues  of  organs  that  are  naturally 
devoid  of  pigment. 

(9)  When  quite  fresh,  sarcomas  do  not  yield  a 
lactescent  juice  on   scraping,   but  soon  after  removal 


494  Surgical  Pathology.         [Chap.  xciv. 

a  liquefaction  of  tlie  intercellular  substance  takes 
place,  and  the  cells  are  thus  loosened  from  one 
another.  Then  a  milky  fluid  can  be  easily  obtained, 
certainly  within  twelve  hours. 

Speaking  broadly,  sarcomas  are  not  so  malignant 
as  cancers,  but  they  differ  from  them  less  in  this 
respect  than  do  the  various  forms  of  sarcoma  amongst 
themselves ;  e.g.,  a  round-celled  subperiosteal  sarcoma 
of  a  long  bone  may  end  fatally,  with  all  the  signs  of 
malignancy,  within  six  months,  whilst  a  central 
myeloid,  after  amputation  of  a  limb,  may  neither  recui 
locally  nor  in  distant  parts. 


INDEX. 


Abscess,  Acute,  7. 

Acute  aortic  endarteritis,  287. 

endarteritis,  286. 

interstitial  nephritis,  372. 

iritis,   congenital    syphilitic, 

142. 

lichen,  130. 

necrosis,  58,  68. 

orchitis,  319. 

osteomyelitis,  227. 

— —  periostitis,  225. 

peritonitis,  393. 

serous  synovitis,  261. 

■  total  necrosis,  238. 

A'lenocele  of  the  breast,  -460. 
Adenoid  cancer,  481. 

tumours,  458. 

Adenoma,  460. 

of  the  hreast,  461. 

parotid,  462. 

prostate,  462. 

Adenomatous  polypus,  388. 
Adhesive  peritonitis,  398. 
Adipocere,  100. 
Albuminoid  infiltration,  1 17. 

,  Anatomy  of,  119. 

Alveolar  cancer,  475. 

sarcoma,  445. 

Amyeline  neuromata,  431. 
Amyloid  infiltration,  117. 
Aneurism,  2£0. 

of  the  cerebral  arteries,  309. 

of  femoral  artery,  293. 

of  middle  cerebral  artery,  294. 

Aneiirismal  varix,  291. 
Angiomata,  The,  434. 
Anthracsemia,  81. 
Anthrax,  78. 

Anus,  Ulcers  of  the,  879. 
Areolar  hyperplasia,  85. 
Argyll-Robertson  pupil,  127. 
Arteiio-capillai-y  fibrosis,  289. 

venous  aneurism,  291. 

Arteritis,  285. 
deformans,  288. 


Arthritis  deformans,  256,  260. 
Artificial  anus,  402. 
Ataxic  arthropathy,  126. 
Atheroma  of  the  cerebral  arteries, 

97. 
Atony  of  the  bladder,  355. 
Atrophic  scirrhus,  476. 
Atrophies    from    deprivation    of 

blood,  87. 

from  functional  activity,  87. 

,  Natural  or  physiological,  86. 

of  nervous  origin,  87. 

Atrophy,  85. 

,  Fatty,  88. 

,  Modes  of,  87. 

of  bone,  89. 

of  muscle,  90. 

of  nerves,  91. 

of  testicle,  337. 

Bacillus  anthracis  of  Cohn,  79,  80. 

Bacteridium  of  Davaine,  79. 

Bandy-leg,  276. 

Benign  lymphomata,  450. 

tumours     of    the     bladder, 

362. 
Bile,  Pigmentation  from,  108. 
BLidder,  Tumours  of  the,  360. 

,  Ulceration  of  the,  359. 

Blanching  of  the  hair,  122. 
Blind  boil,  77. 

Blood,  pigmentation  from,  108. 
Blue  line  in  the  gums  of    lead- 

vForkers,  107. 
Boils,  76. 

Bone  abscess,  244. 
Bridle  stricture   of  the  urethra, 

348. 
Bullous  and  vesicular  syphilides, 

137. 
Bursal  cysts,  423. 

Cachexia,  493. 

Calcareous  degeneration,  112. 

Calcification  in  the  arteries,  11-5. 


496 


Surgical  Pathology. 


Calciftcation  in  the  lieart,  114. 

• in    the    memhranes    of    the 

brain,  116. 

in  new  growths,  116. 

iu  old  age,  113. 

in  the  veins,  116. 

of  hydatid  cysts,  116. 

,  Partial  and  complete,  114. 

,  Secondary,  115. 

Calcified  patches  under  the  micro- 
scope, 114. 

Calculi,  Table  of,  377. 

Callo\is  ulcer,  27. 

Calltis-formation,  179. 

Cancer  of  the  prostate,  368. 

Cancerous  depo-^it,  11. 

tubercle,  153. 

Cancers  and  sarcomas  con- 
trasted, 491. 

Cancrum  oris,  40. 

Carbuncle,  77. 

Carcinomata,  The,  474. 

Caries,  2u7,  209. 

fiingosa,  160,  209,  211. 

,  Nature  of  the  discharge  in, 

213. 

necrotica,  212. 

non-suiipurativa,  209. 

of  the  iiip  joint,  189. 

of  the  spine,  214. 

•  of  the  vertebrae,  214. 

,  process  of  ciire  in  the  spine, 

216. 

Cartilage  wounds  or  fractures,  178. 

Cartilaginous  transformation  of 
the  callus,  180. 

Caseation,  10. 

Caseous  inflection,  157. 

Catarrh,  The  term,  357. 

Catarrhal  ophthalmia,  160. 

Cauliflower  excrescences,  455,  487. 

Cavernous  augiomata,  435. 

Cells  from  inflamed  tissue,  4. 

Cellulitis,  75. 

Central  necrosis,  237. 

Cephalhsematoma,  194. 

Cerebral  abscess,  201. 

meningocele,  282. 

softening,  96. 

Cerebro-spinai  flmil,  281. 

Cerebrum,  Suppurative  inflamma- 
tion of  the,  8. 

Chancres,  31. 

Charcot's  disease,  126,  189,  193. 

Chimney-sweep's  cancer,  485. 

Cholesterine,  100. 

Chondro-sarcoma,  448. 

. of  the  testicle,  334. 

Choroiditis  syphilitica,  143. 


Chronic  abscess,  12. 

endarteritis,  287. 

enlargements  of  the  testicle, 

321. 

inflammation,  11. 

interstitial  nephritis,  372. 

osteoplastic  ostitis  and  peri- 
ostitis, 219. 

peritonitis,  893. 

rheumatic  arthritis,  12,  256. 

serous  synovitis,  262. 

Cicatrisation,  169. 

of  an  ulcer,  20. 

Cirrhoses,  301. 

Cirsoid  aneurism,  296. 

Cleft  palate,  282. 

Clonic  spasm,  47. 

Clot  within  the  aneurism,  293. 

Colloid  cancer,  482. 

of  ovary,  483. 

degeneration,  104. 

Columnar  epithelioma,  481. 

of  rectum,  386. 

Compound  f  ractui-e  with  necrosis, 
191. 

fractures.  Union  of,  190. 

Condensiug  ostitis,  210,  223. 

Congenital  hydrocele,  340. 

nsevi,  434. 

syphilis,  141. 

,  secondary  and  tertiary 

symptoms,  144. 

Congestive  stricture  of  the  ure- 
thi-a,  346. 

Connective  tissue  hypertrophy, 
125. 

Contagious  carbuncle,  78. 

Continuous  pain,  1.5. 

Corpora  amy]acea,  120,  369. 

Corpuscles  of  Gluge,  4,  9. 

Counter-irritantsreHevingpain,16. 

Cranial  bones.  Lesions  of,  in  con- 
genital syphilis,  228. 

Craniotabes,  151,  228. 

Cranium  aif  ected  in  syphilis,  229. 

Croupous  disease  of  granulations, 
23. 

Curvature  of  the  spine,  272. 

Cutaneous  eruptions  in  syphilis, 
142. 

system  in  nervous  affections, 

122. 

Cystic  degeneration,  246. 

epithelioma,    multiple,     of 

lower  jaw,  102. 

myeloid  sarcoma  of  the  fe- 

miu',  443. 

ossifying    enchondroma     of 

the  femur,  418. 


Index. 


497 


Cystic  sarcocele,  335. 
Cystitis,  356. 
Cysts,  464. 

Dead  tissues  in  gangrene,  Changes 

in  the,  35. 
Defective  growth  of  radius  after 

fracture,  185. 
• vascular  supply  in  fractures, 

186. 
Definitive  callu=!,  183. 
Deformities,  268. 

in  rickets,  148. 

Diarthrodial  pseudarthrosis,  188. 
Diathesis,  11. 

Diffuse  adenoma,  462. 

fibromata,  410. 

funicular  hydrocele,  341. 

hypertrophy  of  hone,  223. 

strumous  orchitis,  326. 

traumatic  aneiirisms,  290. 

Diphtheria  of  the  granulations  in 
ulceration,  25. 

of  wounds,  26. 

Discoloration  of  the  skin  by  silver 

nitrate,  107. 
Diseases    of  the  granulations    in 

ulceration,  23. 
Dissecting  aneurism,  297. 
Disseminated  tubercular  orchitis, 

331. 
Double-descending  optic  neuritis, 

141. 
Dry  arthritis,  256. 
Dupuytren's  spur,  402. 

Ear,   Congenital  sypbilitic    affec- 
tions of  the,  143. 
Echinococcus,  471. 
Eclamptic  convulsions  in  fever,  46. 
Ectopia  vesicae,  284. 
Elephantiasis  Arabum,  411. 
Emboli,  Paths  of  transit  of,  306. 
Embolic  aneurisms,  297. 
congestion  of  the  lung,  305. 

infarction  of  the  spleen,  308. 

Embolism,  304. 
Embryo-plastic  tumour,  440. 
Encephaloid  cancer,  333. 
of  testicle,  480. 

cancers,  479. 

sarcoma,  440. 

Enchondroma,  335,  415. 

Enchondromata,  Classification  of, 
417. 

Encysted  hydrocele  of  the  epi- 
didymis, 339,  340. 

Ends  of  divided  muscular  fibres, 
175. 

Enostoses,  421. 

G  G 


Epididymis,  326. 

Epididymitis,  319. 

Epiphysial  fractures,  184. 

osteomata,  422. 

Epispadias,  285. 

Epithelioma,  361. 

of  the  anus,  385. 

of  the  thumb,  486. 

Erysipelas,  69. 

,  Infectious,  57. 

,     Phlegmonous     or    cellulo- 

cutaneous,  73. 

of  the  scalp,  195. 

Erysipelatous  lymi)hangitis,  73. 

Erythema,  71. 

Exophthalmos,  201. 

Exostoses,  421,  424. 

Extravasation  of  urine,  350. 

Extroversion  of  the  bladder,  284. 

Exudation  stage  in  the  union  of 
wounds,  168. 

Eye,  Congenital  syphilitic  affec- 
tions of  the,  142. 

in  lesions  of  the  brain  and 

spinal  cord,  128. 

False  joints,  1&7. 

Fascicular  neuromata,  431. 

Fatty  degeneration,  94. 

,  Microscopy  and  chemis- 
try of,  100. 

of  arteries,  285. 

of  the  heart,  97. 

infiltration,  92. 

tumour,  414. 

Fever,  41. 

Fibrillar  tremor  of  the  muscles  in 
fever,  46. 

Fibroma  molluscum,  410. 

Fibromata,  The,  408. 

Fibroses,  301. 

Fibrous  polypus,  363,  389,  411. 

Fistula  in  ano,  391. 

Flexion  of  the  joints  in  inflam- 
mation, 254. 

Fracture  of  the  spine,  273. 

simulated  in  rickets,  150. 

Fractures  of  bone,  178. 

of  rickety  bones,  148. 

Fungating  ostitis,  211. 

Fungous  inflammation  in  the 
knee-joint,  253. 

testis,  327. 

Fungus  disease  of  granulations,  24. 

hsematodes,  333,  479. 

Furuncles,  76. 

Fusiform  aneurisms,  296. 

Gall  stones  and  urinary  calculi, 
378. 


498 


Surgical  Pathology. 


Gall  stones,  pigmentation  in,  108. 

Gangrene,  10,  34.         _ 

Gangrenous  stomatitis,  40. 

Gelatinoform  atrophy,  229. 

Genito-urinary  system  in  loco- 
motor ataxia,  127. 

Genu  valgum,  276. 

Giant  cells,  Origin  of  the,  in 
tubercle,  156. 

Glioma,  446. 

Gliosarcoma,  446. 

Gonorrhcea,  341. 

Gonorrhceal  affections  of  the  eye, 
344. 

■ arthritis,  265. 

conjunctivitis,  345. 

cystitis,  .343. 

orchitis,  344. 

rheumatism,  265. 

stricture  of  the  urethra,  344. 

Granular  and  crystalline  pigment 
from  cerehral  basmorrhage,  109. 

Granulation  of  a  wound,  171. 

sarcoma,  437. 

tissue,  6, 

Grey  granulation  of  the  liver, 
155. 

miliary  granulations,  153. 

Gummata,  133,  139. 

Gunpowder  explosions.  Discolour- 
ing by,  107. 

Hsematoma,  194. 
Hsematuria,  364. 
Haemorrhage  between   the    skull 

and  dura  mater,  197. 

from  the  bladder,  365. 

— —  from  the  kidney,  364. 

from    the     prostate     and 

urethra,  366. 

from  the  ureters,  365. 

from  hsemophilia,  266. 

into  joints,  266.    _  ■ 

Haemorrhagic    condition   of    the 

granulations  of  an  ulcer,  25. 

infarction,  308,  307. 

peritonitis,  397. 

Hgemorrhoids,  390. 

Hare-lip,  284. 

Healing  by  granulation,  170. 

by  scabbing,  173. 

• stage  of  an  ulcer,  19. 

Heat  in  inflammation,  2. 
Hereditary   multiple   osteomata, 

423. 
Hernia  cerebri,  196. 

• testis,  327. 

Hei-pes  zoster,  123. 
Heteroplastic  tumours,  405. 


Hip  affected  with  strumotis  arthri- 
tis, 255.    . 
deformities,  276. 

joint    affected  with  chronic 

rheumatic  arthritis,  259. 

disease,  256. 

Histology  of   grey  granulations, 
154. 

of  the  granulations  forming 

the  base  of  an  ulcer,  20. 

Homoplastic  tumours,  405. 
Horse-shoe  fistula,  391. 
Hospital  gangrene,  26,  39. 
Hospitahsm,  40. 
Howship's  lacunae,  209. 
Hyaline  masses  in  joints,  268. 
Hydrocele,  337. 

of  the  cord,  340. 

of  the  hernial  sac,  402. 

of  the  tunica  vaginalis,  338. 

Hydro-meningocele,  279. 

myelocele,  279. 

Hydrops  acutus,  261. 

articulorum,  262. 

Hygroma,  465. 
Hyperpyrsexia,  98. 
Hypertrophies,  81. 
Hypertrophy  and  dilatation  of  the 
ureters,  355. 

of  the  bladder,  354. 

of  the  facial  bones,  224. 

of  the  prostate  gland,  366. 

,  Physiological,  85. 

Hypospadias,  284. 

Ichorbsemia,  63. 

Infantile    paralysis.    Deformities 

from,  276. 
Infective  origin  of  tubercle,  156. 
Inflammation,  1. 

of  an  ulcer,  26. 

of  bone,  205. 

Inflammatory    changes    in    bone 

fracture,  179. 
Innocent  tumours  of  the  rectum, 

3S8. 
Inspissated  pus,  13. 
Interarachnoid  suppuration,  199. 
Intermittent  pain.  15. 
Internal  anthrax,  81. 

necrosis,  237. 

Interstitial  keratitis,  143. 
Intracranial  suppuration,  198.     * 

syphihs,  139. 

Intracystic  tumours,  447. 
Intraspinal  syphilis,  139. 
Intussusception  of  the  bowel,  403. 
Irritable  ulcer,  27, 
Irritative  dropsy,  281. 


IXDEX. 


499 


Irritative  overgrowth,  85. 

Iritis,  140. 

Itcliing   in    syphilitic    eruptions, 

135. 
Ivory  osteomata,  422. 

Joint  murrain,  78. 

Joints,  Diseases  of  the,  249. 

,  Trophic  lesions  of,  126. 

Keloid  mass,  7. 
Keratitis  punctata,  143. 
Kerato-iritis,  143, 
Kyphosis,  216. 

Lacerated  wounds,  172,  174. 
Lardaceous  infiltration,  117. 
Lateral  curvature  of  the  spiae,  274. 
Leucocytes,  3. 

,  Diapedesis  of,  4. 

Leucocythsemia,  453. 
Ligamentous  pseudarthrosis,  187. 
Ligature  of  arteries,  298. 

,  Cuctiag  through  of  the 

ligature,  299. 

Lipomata,  The,  412. 
Lipomatous  bodies  in  joints,  288. 

sarcoma,  448. 

Liquor  puris,  9. 

sanguinis,  9. 

Living  sequestrum.  A,  212. 
Locality  of  ulcers,  22. 
Locomotor  ataxy,  126. 
Lociis  resistentiae  miuoris,  13. 
Long  bones.  Congenital  syxihilitic 

lesions  of,  230. 
Lumho-sacral  spina  bifida,  280. 
Lupoiis  ulcer,  30. 

ulceration,  164. 

Lupus,  162. 

erythematosus,  163. 

exedens,  163,  164. 

vorax,  163. 

Lymphadenomata,  The,  449. 
Ljmphangiomata,  The,  454. 
Lymphatic  nsevi,  454. 
Lymphatics  affected  by  striunous 

disease,  161. 
Lymphoid    or    adenoid    tissues, 

Oriain  of,  155. 
Lymphomata  of  the  viscera,  etc., 

452. 
Lympho-sarcoma,  445. 

Malignant  anthrax  oedema,  80. 

faci;d  carbuncle,  78. 

growths,  11,  406. 

iympbomata,  451. 

pustule,  78. 


Malignant  rectal  ulcer,  382. 

sarcocele,  332. 

ulcers,  29. 

Malum  coxae  senilis,  256. 

Maxillae  and  teeth,  Congenital 
syphilitic,  231. 

Medullated  neiiromata,  431. 

Melanin,  109. 

Melanoma,  110. 

Melanotic  sarcoma,  446. 

of  muscle,  109. 

Melon-seed  bodies  in  joints,  266. 

Meningo-encephalocele,  282. 

Metastases,  Causes  of,  64. 

in  pyaemia,  ^. 

Miliary  aneurisms,  297. 

Milk  teeth  in  riciets,  152. 

Modified  ossification  in  rickets, 
146. 

Moist  gangrene,  37. 

Mollities  ossium,  193,  245. 

contrasted  with  caries, 

249. 

Molluscum  fibrosum,  410. 

Mouth  and  nose.  Congenital  sy- 
philitic affections  of  the,  142. 

Movement  of  the  fragments  after 
fracture,  186. 

Mucin,  103. 

Mucoid  degeneration,  100. 

Mucous  papillomata,  456. 

- — -  polypi  of  the  bladder,  383, 
364,  429. 

sarcoma,  447. 

tissue,  Distribution  of,  101. 

tubercles,  32,  142. 

Muscle  wounds,  174, 

Muscular  system  in  fever,  45. 

Myeloid  epulis  from  the  lowe'- 
jaw,  444. 

sarcoma,  443. 

Myo-fibroma  of  uterus,  432. 

Myomata,  The,  431. 

with  striped  fibres,  433. 

Myxo-chondroma  of  parotid  gland, 
416. 

Myxoedema,  105. 

Myxomata,  The,  427. 

Myxomatous,  or  gelatinous  poly- 
pus, 389. 

Myxo-sarcoma,  448. 

Nasal  mucous  polypi,  428. 
Naso-bucco-pharyn.:eal  cavity,283. 

-pharyngeal  polypi,  428. 

Natural  ossification,  145. 
Necrosed  part  in  gangrene,  36. 
Necrosis,  232. 
contrasted  with  caries,  218. 


500 


Surgical  Pathology. 


Necrosis  of  an  amputation  stnmp, 
235. 

of  the  femur,  238. 

Nerve  injuries  and  wounds,  176. 
Nervous  system  in  fever,  45. 
Neuralgic  pain,  15. 
Neuromata,  410,  430. 
Nodes,  222. 

,  Varieties  of,  222. 

Nodular  masses  in  joints,  267. 

rheumatism,  256,  258. 

Nomenclature  of  ulcers,  21. 
Non-medullated  neuromata,  4S1. 

Odontomata,  The,  425. 

Opposed     graniolating     surfaces. 

Union  of,  172. 
Orbital  cellulitis,  204. 
Orchitis,  following  gonorrhoea, 319. 
Organic  stricture  of  the  urethra, 

347. 
Osseous    and     articular     trophic 

lesions,  127.  ' 
Ossific  union,  Failure  of,  185. 
Ossification  of  the  callus,  182. 
Ossiform  tissue  of  Broca,  145. 
Ossifying  enchondromata,  423, 

sarcoma,  448. 

Osteoclasts,  209. 
Osteoid  chondroma,  426. 

tissue  of  Virchow,  146. 

tumour,  426. 

Osteomalacia,  245. 
Osteomata,  The,  419. 
Osteophlebitis,  227. 
Osteophytes,    Formation    of,    in 

locomotor  ataxia,  126. 
,  Congenital  syphilitic,  of  the 

long  bones,  231. 

,  Varieties  of,  220. 

Osteoplastic  ostitis.  Internal,  223. 
Osteoplasts,  182. 
Osteo-thrombosis,  227. 
Ostitis,  Causes  of,  206. 

deformans,  224. 

,  Terminations  of,  206. 

Otitis  media,  144. 

Pachymeningitis,  189. 
Pain,  13. 

,  Elf ects  of,  on  nutrition,  16. 

,  Factors  of,  14. 

in  inflammation,  2. 

Papillomata,  The,  454. 

of   the    serou&  membranes, 

457. 
Papular  syphilide,  136. 
Paralysed     muscles     in     trophic 

lesions,  125. 


Parrot's    osteophytes    or    nodes, 

229. 
Pathological  aneurisms,  292. 

aneurism.  Varieties  of,  296. 

Pemphigus,  138. 

Perforating  ulcer  of  the  foot,  124. 

Periarteritis,  289. 

Perihepatitis,  144. 

Periosteal  abscess,  225. 

Periosteum,    Changes     in,     after 

fracture,  184. 
Peritonitis,  392. 
Perspiration  in  fever,  44. 
Pes  planus  et  plano-valgus,  275. 
Phagedeeua,  33. 
Phagedsenic  chancres,  31. 
Phlebitis,  Signs  of,  313. 
Phlegmasia  alba  dolens,  31+. 
Phlegmonous  arthritis,  263. 

erysipelas,  37, 73. 

teno-synovitis,  74. 

Phlyctenular  corneitis,  160. 
Phosphorus  necrosis  of  the  jaws, 

242. 
Phthisis  and  fatty  infiltration,  94. 
Pia-meningeal  suppuration,  200. 
Pigment,  Sources  of,  107. 
Pigmentation,  106. 

,  cases  that  it  occurs  in,  110. 

,  False,  106. 

in  syphilitic  eruptions,  135. 

,  True,  107. 

Piles,  379,  390. 

Plantar     and    palmar    psoriasis, 

137. 
Polymorphism  of  syphilitic  erup- 
tions, 134. 
Posterior  synechia,  140. 
Pott's  disease  of  the  spine,  214. 

puffy  tumour,  195. 

Primary  convulsions  in  fever,  46. 

syphilitic  sores,  33. 

Prolapse  of  the  rectum,  389. 
Proliferating  arthritis,  256. 
Prominence  of  the  eye -ball,  204.    . 
Prostate  gland,  diseases  of,  3o6. 
Prostatic  abscess,  368. 

calculi,  369. 

glandular  tumour,  367. 

Prostatitis,  368. 
Provisional  callus,  183. 
Psammomata,  The,  449. 
Pseud  arthroses,  178,  187. 
Pseudarthrosis    from    traumatic 

dislocation,  189. 
from  xinreduced  dislocation, 

189. 
Pseudo  -  hypertrophic     paralysis, 

93. 


Index. 


501 


Pulpy    degeneration  of    synovial 

membrane,  251. 
Pulsating  swellings  in  tlie   scalp, 

195. 
Pulsation  of  tlie  eye-ball,  203. 
Purposive  atropby,  87. 
Purulent  diathesis,  63. 

infection,  63. 

oplithalmia,  345. 

Pus  corpuscle?.  Origin  of,  10. 

disease,  63. 

Pustular  conjunctivitis,  160. 
Pyaemia,  50. 

,  changes  in  the  wound,  63 

,  course  and  character  of  the 

symptoms,  65. 

,  Idiopathic,  67. 

,  Post-mortem  signs  of,  QQ. 

,  Synonyms  for,  63. 

Pyogenic  membrane,  8. 
Pyohsemia  simplex  et  multiplex, 

63. 
Pyramidal  cataract,  143. 
Pyrexia,  42. 

Quarter  evil,  79. 
Quiet  necrosis,  243. 

Ea-cemose  aneurism,  296. 
Earefying  fungous  ostitis,  210. 

ostitis,  207. 

Pecto-vesical  fistula,  353. 
Eectum,  Stricture  of  the,  332. 

,  Tumours  of  the,  885. 

,  TJlcers  of  the,  380. 

Eedness  in  inflammation,  2. 
Eeflex  subdual  of  pain,  16. 
Eeproduction  of  epitheliiim,  21. 
Eesidual  abscesses,  13. 
Eetinitis  syphilitica,  140,  143. 
Eeverdin's  skin-graftiLg,  21. 
Eheumatic  gout,  256. 
Eickets,  113,  145,  193. 
Eickety  joiats,  152. 

rose-garland,  151. 

spine,  151. 

tibia,  149. 

Eigor  in  fever,  46. 
Eodent  ulcer,  490. 
Eound-celled  sarcoma,  440. 
Eupia,  1.34,  138. 
Euptured  aneurism,  293. 

Sacculated  aneurism,  291. 
Sago  spleen,  119. 
Saliva  in  fever,  44. 
Sarcocele,  321. 
Sarcoma,  335,  362. 
of  the  rectum,  387. 


Sarcomata,  The,  437. 

Scalp  injuries  and  diseases,  193. 

wounds,  195. 

Scirrhus  of  the  prostate,  3G8. 

of  the  breast,  475. 

Scleroses,  301. 
Sclerosing  ostitis,  210. 
Sclerosis  ossium,  223. 
Sclerotitis,  345. 
Scrofula,  158. 

,  Period  of  life  for,  162 

Scrofulous  diathesis,  158. 

orchitis,  329. 

sarcocele,  326. 

,  Minute  anatomy  of,  330. 

testicle,  161,  326. 

tubercle,  153. 

ulcers,  30. 

Secondary  clot,  299. 
Senile  osteoporosis,  193. 

scrofula,  162. 

thickening  of  the  skull,  225. 

Separation  of  the  fragments  after 

fracture,  186. 
Sepsin,  53. 
Septic  infection,  52. 

infection,  Diagnosis  of,  c8. 

intoxication,  52. 

,  Diagnosis  of,  59. 

Seijticsemia,  50. 

,  Character  and  course  of  the 

symptoms  in,  59. 
Septopysemia,  51. 
Sequestrotomy,  2-38. 
Sequestrum,  34,  236. 
Serous  cysts,  465. 
Shooting  pains  in  cancer,  15. 
Simijle  angiomata,  434. 

fracture  of  bone,  178. 

gi'eenstick  fracture  of  radius, 

181. 

rarefying  ostitis,  209. 

sarcocele,  321. 

surgical  fever,  47. 

Site  of  syphilitic  eruptions,  135. 
Sloughing  phagedsena,  40. 

ulcer,  33. 

Soft  chancre,  18. 

Softening  cysts,  98. 

Spasmodic  stricture  of  theurethi-a, 

346. 
Specific  symptomatic  ulcers,  31. 
Spermatocele,  340. 
Sphacelus,  34. 
Spina  bifida,  278. 
Spinal  absce.'ses,  216. 

cord  in  tetanus,  165. 

Spindle-celled  sarcoma,  441. 
Spine,  Fixity  of,  in  caries,  215. 


5o: 


Surgical  Pathology. 


Splenic  fever,  78. 
Spougeoid  tissue,  146. 
Spongy  osteomata,  422. 
Spontaneous  aneurisms,  292. 

• fracture,  193. 

Spreading  stage  of  an  ulcer,  18. 
Squamous  epithelioma,  484. 

sypliilide,  136. 

Stationary  stage  of  an  ulcer,  19. 
Stearic  acid  crystals,  99,  100. 
Strangulated  hernia,  399. 
Strumous  arthritis,  251. 

caries,  210. 

orchitis,  161. 

rarefying  ostitis,  210. 

testis.  Section  of,  328. 

ulcers,  30. 

Subungual  exostoses,  448. 
Superficial  caries,  213. 

necrosis,  233. 

• rarefying  ostitis,  212. 

Suppuration,  7. 

between  the  bone  and  dura 

mater,  199. 

• in  the  mastoid  cells,  202. 

Suppurative  arachnitis,  200. 

arthritis,  263. 

Surgical  fever,  Stages  of,  49. 

kidney,  370. 

Symptomatic  ulcers,  21,  28. 
Syphilis,  128. 

of  the  larynx,  139. 

,  Secondary  and  tf  rtiary,  131. 

SyphUitic  acne,  130, 137. 

caries,  216. 

• chancres.   Unity  and  duality 

of,  129. 

disease  of  arteries,  288. 

disease  of  the  cranium,  217. 

eruptions,  134. 

- — -  eye  aftections,  140. 

gumma  of  the  liver,  133. 

lepra,  136. 

orchitis,  323. 

pseudo-paralysis,  230. 

psoriasis,  135. 

rectal  ulcer,  381. 

sarcocele,  322. 

ulcers,  31. 

,  Secondary,  32. 

,  ,  of  the  throat  and 

motith,  32, 

,  Tertiary,  32. 

Swelling  in  inflammation,  2. 

Tabes  mesenterica,  162. 
Talipes  equino-varus,  274. 

■ equinus,  275. 

valgus  et  caleaneo-valgus,  275. 


Tattooing  discolourings,  107. 

Telargiectases,  434. 

Tertiary  phagedeenic  ulceration, 
33. 

Tetanic  spasm,  47. 

Tetanus,  164. 

Throbbing  pain,  15. 

Thrombosis,  310. 

— —  in  common  carotid  artery, 
316. 

,  Eelation  of,  to  phlebitis,  312. 

Tibia  affected  with  ostitis  defor- 
mans, 149. 

Tissues  attected  in  scrofula   and 

.  tubercle,  160. 

Tonic  spasm,  47. 

Traumatic  fever,  47. 

— ,  Cause  of,  48. 

hgemarthrosis,  266. 

suppurative  arthritis,  263. 

Trophic  lesions,  121. 

nerves,  122. 

Tubercle,  153. 

. com]pared  with  pyaemia,  157. 

,  General  pathology  of,  156. 

of  bone,  153,  213. 

of  the  prostate,  368. 

Tubercular  meningitis,  45,  201. 

orchitis,  161. 

syphihde,  135,  137. 

testis,  153,  326. 

ulcers  of  the  intestine,  83. 

Tumours,  405. 

,  Classification  of,  407. 

of  the  scalp,  195. 

Tunica  vaginalis  in  syphilitic 
orchitis,  325. 

Types  of  pain,  15. 

Typhoid  ulcers,  33. 

Ulcer,  Simple,  mode  of  its  forma- 
tion, 17. 

,  Stages  of  an,  18. 

Ulceration,  16. 

of  cartilage,  251,  253. 

Ulcerative  form  ot  hospital  gan« 
grene,  40. 

Ulcers  in  terminal  nerve-fibres, 
123. 

in  the  small  intestine,  22. 

of  the  anus  an  1  rectum,  379 

of  the  face,  22. 

of  the  leg,  22. 

on  the  penis,  23. 

Union  of  wounds,  167. 

by  first  intention,  168. 

Ununited  fracture  of  olecranon, 
187. 

of  humerus,  183. 


Index. 


503 


Urethra,  Stricture  of,  3 46. 
Uretliral  fever,  68, 
Urinary  absce.ss,  350. 

deposits.  Table  of,  375. 

fistula,  353. 

Urine  in  fever,  44. 

,  Pigmentation  of,  108. 

,  Retention  of,  in  gonorrhoea, 

344. 

in  surgical  kidney,  374, 

,  Suppression  of,  68. 

Valve  of  Hoiiston,  383. 

Valves  in  varicose  veins,  state  of, 

303. 
Varicose  aneurism,  291. 

ulcer,  28. 

,  Mode  of  origin  of  a,  28, 

Varix,  300. 

,  Calcification  in,  303. 

,  General  pathology  of,  301. 

,  Histology  of,  302. 

Vascular  polypus  of  rectum,  38S. 
Vascularisation  r.f  lymph,  169. 
of  callus,  181. 


Venous  absorption,  5. 

embolism,  304. 

nsevi,  435. 

Vertebrae  absorbed  by  an  aneurism, 

89. 
Vesico-vaginal  fistula,  353. 
Vesicular  eruptions,  122. 
Villous  polypus  of  rectum,  388, 

tumour  of  bladder,  362. 

Visceral  changes  in  rickets,  152. 
lesions  in  congenital  syphilia, 

144. 
syphilis,  138. 

Warts,  455. 
Warty  cicatrix,  31. 

polypus  of  rectum,  389. 

Waxy  infiltration,  117. 
Weus,  411. 
White  swelling,  251. 
Wounds  of  tendons,  173. 

Yellow  tubercle,  153. 

Zenkerism,  104. 


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